m 


i 


Exchange  from 
Westmont  College 


2 


COLLEGE   OF   OSTEOPATHIC    PHYSICIANS 
AND   SURGEONS  •   LOS  ANGELES,  CALIFOENIA 


e>«®®€>®®®®e>®«)®e®®®«®®®®e®ee)®®ee®®»ee 


AN 


ANATOMICAL  AND  SURGICAL  STUDY 


FRACTURES     OF    THE     LOWER     END 


HUMERUS 


AN 


ANATOMICAL  AND  SURGICAL  STUDY 


FRACTURES  OF  THE  LOWER  END 


HUMERUS 


BY 

ASTLEY  PASTON  COOPER  ASHHURST,  A.B.,  M.D. 

PROSECTOR     OF    Al'PLIhU     ANATOMY    IN     THE    UNIVl-JRSITY    OF    I'KNNS^  LV  A  N I A ,    SUK(;p;ON    TO    THK    OUT-PATIENT 

DEPARTMENTS    OF    THE    EPISCOPAL    AND    CHILDREN'S    HOSPITALS    OF    PHILADELPHIA,    ASSISTANT 

SURGEON    TO    THE    PHILADELPHIA  ORTHOP.EDIC    HOSPITAL,    FELLOW    OF    THE  COLLEGE 

OF    PHYSICIANS    OF    PHILADELPHIA,    OF    THE  PHILADELPHIA 

ACADEMY    OF     SURGERY,    ETC.,    ETC. 


THE  SAMUEL  D.  GROSS  PRIZE  ESSAY  OF  THE  PHILADELPHIA 
ACADEiMV  OF  SURGERY,  1910 


LEA  k  FEBIGER 

PHILADELPHIA    AND    NEW    YORK 


// 


Man   hat  entweder  gut  reponirt  und  bekommt  gute  Heilung, 
oder  man   hat  schleiht  reponirt  und  bekommt  schlechte  Heilung 


Copyright  1910 
LEA    &    FEBIGER 


GWILYM    G.  DAVIS 

M.D.,   UNIVERSITIES    OF    PENNSYLVANIA    AND    GOTTINGEN 

M.R.C.S.,    ENGLAND 

ASSOCIATE     PROFESSOR    OF    APPLIED    ANATOMY    IN    THE     UNIVERSITY    OF    PENNSYLVANIA 

SURGEON    TO   THE    EPISCOPAL    HOSPITAL 

SURGEON    TO   THE    ORTHOPAEDIC    HOSPITAL 

THIS  VOLUME 

IS    GRATEFULLY    INSCRIBED 

BY    HIS 

PUPIL,    PROSECTOR,    ASSISTANT,    AND    FRIEND 

THE  AUTHOR 


i8z5  I'iNE  Street,  I'hii.adki.phia,  April  26,  1910. 

To  Dr.  Asti.ky  P.  C.  Ashhurst, 

2000  West  Dc  Lanccy  Place,  Phiiadelpliia. 

My  dear  Dr.  Ashhurst: 

It  gives  me  great  pleasure  to  announce  to  you  that  the  Samuel 
D.  Gross  Prize  of  the  Philadelphia  Academy  of  Surgery  for  1910,  amount- 
ine  to  fifteen  hundred  dollars,  has  been  awarded  to  vou  for  your  essay 
entitled  "An  Anatomical  and  Surgical  Study  of  Fractures  of  the  Lower 
End  of  the  Humerus." 

Allow  me  to  congratulate  you,  and  to  assure  you  that  the  Trustees, 
Dr.  Harte,  Dr.  Willard,  and  myself,  believe  your  paper  to  be  one  of 
great  value. 

^  ours  very  sincereh', 

William    j.  Taylor, 

Chairman  of  the  Trustees  of  the  Samuel  D.  Gross  Prize  Fund. 


William  J.  Taylor,  M.D., 
Richard  H.  Harte,  M.D., 
De  Forest  Willard,  M.D., 

Trustees  of  the  Gross  Prize  Fund  and  Library. 

The  conditions  annexed  by  the  testator  are  that  the  prize  "shall  be 
awarded  every  five  years  to  the  writer  of  the  best  original  essay,  not 
exceeding  one  hundred  and  fifty  printed  pages,  octavo,  in  length,  illus- 
trative of  some  subject  in  surgical  pathology  or  surgical  practice,  founded 
upon  original  investigations;  the  candidates  for  the  prize  to  be  American 
•citizens." 

It  is  expressly  stipulated  that  tlie  competitor  who  receives  the  prize 
shall  publish  his  essay  in  hook  form,  and  that  he  shall  deposit  one  copy 
of  the  work  in  the  Samuel  D.  Gross  Librar\  of  the  Philadelphia  Academy 
of  Surgery,  and  that  on  -ts  title-page  it  shall  be  stated  that  to  the  essay 
was  awarded  the  Samuel  D.  Gross  Prize  of  the  Philadelphia  Academy 
of  Surger}'. 

Each  essa\'  must  be  distinguished  by  a  motto,  and  accompanied  by 
a  sealed  envelope  bearing  the  same  motto,  containing  the  name  and 
address  of  the  writer. 


28291 


The  author  is  indebted  to  Dr.  Charles  M.  Montgomery  for  the  excellent 
skiagraphs  of  normal  elbows;  to  Mr.  S.  ].  Riegel,  and  to  his  successors 
as  skiagraphers  to  the  F^piscopal  Hospital,  Drs.  ].  G.  W.  Havens,  Henry 
Winsor,  and  W.  H.  Welker,  as  well  as  to  Dr.  William  Van  Korb,  skiag- 
rapher  to  the  Orthop.Tedic  Hospital,  for  the  skiagraphs  of  the  various 
fractures.  The  photographs,  made  by  the  author,  have  been  skilfully 
retouched  by  Mr.  Charles  F.  Bauer. 

The  experimental  and  anatomical  work  was  done  in  the  laboratory  of 
applied  anatom}*  ot  the  University  of  Pennsylvania.  Most  of  the  patients 
were  treated  m  the  author's  services  at  the  Episcopal  and  the  Children's 
Hospitals. 

As  the  essays  are  submitted  anon\  niouslv,  such  references  as  might 
have  served  to  disclose  the  author's  identity  have  been  added  as  the  work 
was  passing  through  the  press. 

A.  P.  C.  A. 


CONTENTS 


i 


Introduction Ij 

Anatomy 20 

Development  ot  the  Lower  Epiphysis  ottlie  Humerus 30 

Classification 37 

Pathogenesis 49 

Examination  of  the  Patient 56' 

Supracondylar  Fractures 60 

Transverse  Diacondylar  Fractures 73 

Fractures  of  the  External  Condyle 75 

Fractures  of  the  Epitrochlea 78 

Epiphyseal  Separations yg 

Fractures  of  the  Internal  Condyle 81 

Intercondylar  Fractures     ...            86' 

Complications 87 

Dressing  the  Elbow  in  Hyperflexion 88 

Results          gj 

Clinical  Histories 99- 

Supracondylar  Fractures loi 

Transverse  Diacondylar  Fractures 122 

Fractures  of  the  External  Condyle 135 

Fractures  of  the  Epitrochlea 144 

Separation  of  Lower  Epiphysis  of  Humerus 146 

Fractures  of  the  Internal  Condyle 154 

Intercondylar  Fracture         158- 


AN  ANATOiMICAL  AND  SURGICAL  STUDY  OF 

FRACTURES  OF  THE  LOWER  END  OF 

THE  HUMERUS 


It  may  seem  a  work  of  supererogation  to  study  anew  a  subject  which 
has  already  been  so  abl\'  discussed  b}'  AlHs,  Roberts,  Stimson,  Lane, 
Cotton,  Chutro,  Mouchet,  Destot,  Vignard,  Barlatier,  and  other  sur- 
geons ot  experience;  and  this,  mdeed,  was  m\'  own  opinion  until  recentlw 
But  evidences  which  constantly  recur,  both  in  literature  and  in  practical 
work,  demonstrating  the  actual  ignorance  of  otherwise  well-informed 
surgeons  anent  the  anatomy  and  surgery  of  the  elbow  region,  have  con- 
vinced me  that  a  further  study  of  this  subject  is  really  of  importance. 
To  limit  the  scope  of  this  essay,  it  has  seemed  best  to  confine  it  to  a  dis- 
cussion of  recent  fractures  involving  the  lower  end  of  the  humerus. 

The  older  surgeons  gained  their  experience  of  these  injuries  in  the 
period  before  the  use  of  the  X-rays  made  possible  the  control  and  cor- 
rection of  a  diagnosis;  and  many  of  the  younger  surgeons,  taught  by 
them,  are  growing  up  with  the  idea  that  after  any  such  fracture  a  stiff 
elbow  is  to  be  anticipated;  and  that  to  prevent  its  development  the 
most  important  thing  is  to  encourage  early  motion — even  to  insist  upon 
it  to  the  extent  of  attempting  to  secure  it  by  repeated  and  forcible 
manipulations. 

Even  those  surgeons  who  have  given  particular  attention  to  the  subject 
of  elbow  fractures  do  not  claim  to  achieve  very  good  results.  Thus, 
Destot,  Vignard,  and  Barlatier,  in  their  recent  very  admirable  work 
upon  the  subject  (Paris,  1909),  think  that  "in  about  half  the  cases  the 
ultimate  results  are  bad;"  and  Mouchet  (1909),  who  has  himself  had 
an  extensive  experience  (169  cases),  admits  that  though  the  proportion 
given  by  Destot,  Vignard,  and  Barlatier  is  exaggerated  if  it  applies  to 
elbow  fractures  in  general,  yet  it  appears  to  him  exact  if  reference  is 
made  only  to  supracond\iar  fractures  (the  most  frequent  variety).  He 
writes  that  "the  remote  results  are  nearly  always  satisfactory  in  the 
fractures  of  the  epitrochlea;  satisfactory  also,  but  less  uniformly,  in 
fractures  of  the  external  condyle;  .  .  .  these  remote  results  are 
bad  in  half   the  cases  of  transverse  supracondylar  fractures."     Chutro 


IS  FR^CrUIiKS  OF  THE  FUlOir 

(loc.  cir,  p.  143),  with  an  experience  of  35  supraconcl\  lar  fractures, 
writes  that  the  prognosis  should  be  reserved:  ' '  1  here  are  not  wanting 
those  wlio  give  a  favorable  prognosis,  being  deceived  bv  the  happy 
termination  of  one  or  two  cases  which  thev  have  seen;  but  u  hen  these 
become  more  numerous  they  will  learn  that,  in  spite  of  most  pains- 
taking treatment,  there  will  be  unfortunate  cases  resulting  in  impaired 
function,  and  all  this  under  the  direct  care  of  the  ph}sician,  without 
his  being  able  to  prevent  it."  Even  for  supracond\lar  fractures  with- 
out displacetnent,  Churro  sa\s  (p.  146)  that  the  patient  and  his  family 
should  be  told  that  although  the  prognosis  is  more  favorable  than  in 
other  cases,  yet  that  the  range  of  motion,  though  free,  will  not  equal 
the  normal.  For  fractures  involving  the  joint  (external  or  internal 
cond\le,  epiphyseal  separations,  and  transverse  diacond\lar  fractures), 
both  Mouchet  and  Chutro  give  a  still  more  gloomy  prognosis.  Among 
^g  recent  fractures  of  the  lower  end  of  the  humerus  treated  bv  Destot, 
Vignard,  and  Barlatier,  what  might  be  called  a  perfect  result  was  ob- 
tained in  onl\'  1 1,  and  in  this  class  of  "  perfect"  they  include  slight  degrees 
of  deformity  not  materially  interfering  with  functional  use  of  the  arm; 
among  loi  ancient  fractures  of  the  elbow  region  which  they  investigated, 
they  found  that  a  "  perfect"  result  had  been  obtained  in  38  (only  37.6 
per  cent.).  Among  32  fractures  of  the  lower  end  of  the  humerus  studied 
very  carefully  by  Cotton,  there  were  onl\-  5  m  which  a  perfect  result 
could  be  claimed,  and  in  one  of  these  live  there  was  slight  cubitus  valgus. 
Cotton  concluded,  from  his  study,  that  in  fractures  of  the  external  condyle 
some  limitation  of  extension  was  to  be  expected,  as  also  in  separations 
of  the  internal  epicondyle;  while  in  supracondylar  fractures  he  expected 
moderate  loss  of  flexion  and  frequent  deformit\',  usualh-  of  the  gunstock 
variety. 

Most  of  the  text-books  at  present  in  use  also  give  an  unfavorable 
prognosis.  Da  Costa  says:  "The  prognosis  for  complete  restoration 
of  function  is  bad,  and  in  most  of  these  fractures  some  deformity  and 
considerable  stiffness  are  inevitable.  Ank\losis  partial  or  complete 
is  a  not  unusual  sequence."  Brewer  writes:  "The  prognosis  in  every 
case  should  be  guarded."  Wharton  sa\s:  "When  fractures  of  the  lower 
extremity  of  the  humerus  involve  the  elbow-joint,  a  certain  impairment 
of  joint  motion  is  apt  to  occur  either  from  ankylosis  or  from  displace- 
ment of  the  fragments.  .  .  .  It  is  well  to  explain  to  the  patient  or  his 
friends  that  impairment  of  joint  motion  may  result  in  these  fractures  in 
spite  of  the  greatest  skill  and  care  in  the  treatment."  Stewart  states: 
"The  prognosis  of  fractures  about  the  elbow  should  be  guarded,  and 
the  danger  of  limitation  of  motion  explained  to  the  patient.  In  most  in- 
stances, however,  a  useful  arm  is  obtained,  although  this  ma\'  not  be  for 
a  number  of  months."     Pilcher  says:    "Some  limitation  of  the  motions 


CURRENT  TEJCH/NC  19 

of  this  joint  is  the  rule  after  fracture  in  its  \  icinitv,  and  complete  anky- 
losis is  not  infrequent."  Scudder  says:  "At  the  time  of  the  first  examina- 
tion of  the  elbow  the  nature  of  the  injury  and  its  seriousness  should  be 
explained  carefully  to  the  patient  or  his  friends.  A  guarded  outlook 
should  be  expressed,  particularly  with  reference  to  the  function  of  the 
joint.  Some  limitation  of  motion  may  exist  after  all  that  is  possible 
has  been  done."  Miles  and  Thomson  say:  "Ankylosis,  or,  more  fre- 
quently, locking  of  the  joint,  is  a  common  sequel  to  many  of  these  in- 
juries." Rose  and  Carless  give  no  very  definite  prognosis,  hut  say: 
"If  the  joint  has  been  involved,  there  is  a  great  tendency  to  impairment 
ot  its  usefulness,  and  passive  movement  should  be  started  earh  ." 

Very  few  surgeons  give  a  favorable  prognosis.  Roberts,  it  is  true, 
as  long  ago  as  1891,  stated  very  explicitly  that  he  approached  an  un- 
complicated fracture  of  the  elbow  with  the  same  certainty  of  getting  a 
good  result  as  he  did  in  the  ordinary  fracture  of  the  lower  end  of  the 
radius;  but  he  acknowledged  the  next  vear  that  his  conclusions  were 
based  "on  no  definite  number"  of  cases,  and  that  this  number  had  been 
small.  Tifi^'an\-  (1892)  said:  "In  children,  with  any  reasonabl\-  good 
treatment,  we  will  have  an  arm  which  will  ten  \ears  later  be  an  ex- 
cellent one."  But  ten  years,  it  seems  to  me,  is  a  long  time  to  wait  for 
a  good  result  in  a  case  of  fracture.  Eve  (1907),  though  vagueh',  gives 
a  generally  favorable  prognosis.  Eisendrath  (1907)  says:  "In  a  properly 
managed  case  the  prognosis,  both  in  adults  and  children,  is  good  as 
regards  both  deformity  and  restoration  of  function  of  the  joint."  Wilms 
(1904)  admits  that  "the  prognosis  of  supracondyloid  fracture  with  the 
proper  treatment  is  favorable;"  but  his  further  statement  (loc.  cit., 
p.  174),  that  "active  and  passive  motion  should  be  instituted  in  order 
to  overcome  at  the  earliest  moment  the  resulting  stifl^ness  of  the  joints 
and  fingers,"  shows  that  he  usualh'  anticipates  stifi^"ness;  moreover,  he 
states  (p.  182)  that  "the  involvement  of  the  joint  makes  the  prognosis 
of  fracture  of  the  external  condyle  unfavorable.  .  .  .  For  this  reason 
it  is  important  to  begin  passive  motion  as  soon  as  possible — that  is, 
at  the  end  of  the  second  week,  otherwise  the  limitation  of  motion  is 
overcome  with  increasing  difficult\-." 

Coenen  (1908),  basing  his  opinion  on  a  series  of  35  cases  of  supra- 
condylar fracture  treated  by  LudlofF  and  himself,  concludes  that  it  is 
in  its  results  one  of  the  most  satisfactory  of  all  fractures  seen  in  children; 
but  among  28  recent  cases  which  he  traced,  he  notes  a  perfect  result 
in  only  7,  distinct  limitation  of  motion  in  12,  cubitus  varus  in  7,  cubitus 
valgus  and  Volkmann's  isch;emic  contracture  in  i  case  each. 

It  will  be  noted  that  in  the  above  extracts  from  the  writings  of  teachers 
.  ...  ...  ^ 

of  various   nationalities    the   opinion    is   very   generally    expressed    that 

deformity  and  interference  with  function  are  to  be  anticipated  after  a 


20 


FRACTURES  OF  THE  ELBOW 


fracture  in  tlie  region  ot  the  elbow;  that  those  few  surgeons  who  give 
a  favorable  prognosis  present  no  data  to  support  their  contention;'  and 
that  the  authors  who  have  most  carefully  studied  and  tabulated  their 
results  give  an  even  more  gloomy  prognosis  than  do  the  others.  Now, 
while  I  cannot  hope  to  offer  nuich  that  is  new  in  regard  to  the  applied 
anatomy  ot  the  subject,  I  do  hope  to  show,  b\-  a  detailed  report  of  cases, 
accompanied  in  most  instances  by  skiagraphs,  and  in  many  by  photo- 
graphs, that  with  common-sense  surgical  treatment,  intelligently  applied, 
the  prognosis  ot  any  and  all  fractures  involving  the  lower  end  of  the 
humerus  is  much  less  gloomy  than  it  has  heretofore  been  considered, 
and  that  in  tlw  vast  majority  of  cases  the  ultimate  results  will  be  perfectly 
satisfactory. 

After  a  tew  preliminar\'  remarks  on  the  applied  anatomy  of  the  elbow 
region,  and  a  discussion  of  the  development  of  the  lower  epiphysis  of 
the  humerus,  I  shall  consider  briefl\'  the  causes, 
s\mptoms,  and  treatment  of  tlie  t\pical  fractures 
encountered,  and  shall  add  mv  personal  statistics, 
showing  the  results  obtained. 

ANATOMY. 

The  Adult  Humerus. —  Ihe  humerus  is  a  c\  lindrical 
bone,  its  lower  extremit\'  becoming  gradually  flattened 
antero-posteriorly,  and  broadened  laterally,  and  termi- 
nating in  the  cond\les,  which  ma\  be  roughly  described 
as  a  cylinder  affixed  transverseh'  to  the  front  of  the 
lower  end  of  the  humeral  shaft.  It  is  of  particular 
importance  to  note  that  the  lower  extremity'  of  the 
humerus  is  not  attached  in  the  same  plane  as  the 
shaft  of  the  bone;  it  is  distinctly  on  the  anterior  sur- 
face of  the  shaft  (Fig.  i).  If  it  were  placed  directly 
on  the  end,  the  range  of  motion  of  the  forearm  pos- 
terior to  the  axis  of  the  humerus  would  very  nearly 
equal  its  range  anteriorly  (Fig.  2). 

Looking  at  the  humerus  from  the  front,  it  is 
evident  that  the  articular  surface  is  not  placed  at 
right  angles  with  the  axis  of  the  shaft,  but  obliquely 
(about  85  degrees),  the  lowermost  part  of  the  articular  surface  being 
on  the  inner  side  (Fig.  4).  Thus,  when  the  bones  of  the  forearm  are 
articulated  with  the  humerus,  they  deviate  away  from  the  body,  forming 
the  "carrying  angle"  (p.  27)  (Fig.  3). 


1 

Fig.  I. — Lateral  view  of 
lower  end  of  humerus. 


'  Siter  (1905)  reports  in  general  very  satisfactory  results,  but  specifies  only  6  cases. 


AN  ATOM)-  21 

The  inferior  extremity  of  the  humerus  is  composed  of  the  two  con- 
dyles, external  (or  lateral)  and  internal  (or  medial);  the  depression  in 
the  centre  of  the  shaft  at  the  base  of  the  condyles  (formed  by  the  olec- 
ranon fossa  posteriorly,  by  the  coronoid  fossa  in  front)  lies  luitli/n  the 
elbow-joint  (Fig.  5).  The  articular  part  of  the  external  condyle  is  called 
the  capitellmn,  and  articulates  with  the  head  of  the  radius;  while  the 
articular  part  of  the  internal  condyle  is  called  the  trochlea,  and  articu- 
lates with  the  sigmoid  cavity  of  the  ulna.  The  prominent  tubercle  on 
the  internal  condyle  above  the  trochlea  is  called  the  epitrochlea  (internal 
epicondyle)  and  that  on  the  external  condyle  is  called  the  eptcondyle 
(external  epicondyle)  (Fig.  6).  The  trochlea  is  concave  from  side  to 
side,   and    convex   antero-posteriorlv,   forming  with    the   ulna   a    saddle- 


y\ 


\ 


,// 


\\ 

\    \ 
\    \ 
\   \ 
\ 


\> 


X\ 

\  \ 

\  \ 

\  \ 

\  \ 


Fig.  2. — Diagram  to  show  range  of  motion  in  elbow-jomt. 

shaped  joint  of  considerable  firmness,  and  permitting  only  a  hinge- 
like antero-posterior  motion.  Of  the  two  lips  of  the  trochlea,  the  inner 
is  much  the  more  prominent.  The  capitellum  is  more  or  less  spherical, 
and  adapted  to  the  concave  shape  of  the  radius;  besides  the  antero- 
posterior motion  occurring  in  this  part  of  the  elbow-joint,  the  head  of  the 
radius  also  rotates  in  its  own  axis,  regardless  of  whether  the  elbow  is 
flexed  or  extended,  and  entirely  independently,  therefore,  of  the  relation 
of  the  ulna  to  the  humerus.  If  the  ulna  were  absent,  the  radius  and 
capitellum  would  constitute  practically  a  ball-and-socket  joint,  the 
radial  head  forming  a  shallow  cup;  this  condition  is  simulated  by  frac- 
tures of  the  internal  condyle  (p.  82).  If  the  radius  v\ere  absent,  the 
hinge-like  motion  of  the  ulno-humeral  jt)int  would  still  be  preserved, 
unless  either  the  outer  or  inner  lip  of  the  trochlea  were  fractured,  when 
a  lateral  motion  would  be  possible  until  the  excursion  of  the  ulna  in  either 


22 


IR.lCTi'RKS  OF  Till:   hIJIOII' 


Fig.  3. — 1  he  carrvins;  angle. 


Fig.  4. — Anterior  view  of  Fig.  5. — Sagittal  section  of  elbow-joint,  passing  through 

lower  end  of  humerus.  the   coronoid    and   olecranon    fossae.       The    capsule    was 

distended  before  hardening  in  formalin. 


ANATOMY 


23 


abduction  or  adduction  became  checked  by  the  lateral  ligaments  of  the 
elbow.  In  some  fractures  of  the  external  condyle  (Cases  -58,  40,  41), 
as  will  be  seen  presently,  this  condition  is  present,  and  the  carrying 
angle  may  be  lost  by  adduction  of  the  ulna  due  to  downward  displace- 
ment of  the  external  condyle,  or  may  be  markedly  increased  by  its 
upward  displacement. 

Limits  of  the  Articular  Surface  (Fig.  7). — Anteriorly  the  capsule  is 
attached  to  the  shaft  of  the  humerus  just  nhovc  the  coronoid  and  radial 
fossa;  (Fig.  5).  On  the  inner  side  it  is  attached  to  the  base  of  the  prom- 
inent inner  lip  of  the  trochlea,  leaving  the  epitrochlea  entirely  extra- 
articular but  bringing  the  whole  inner  lip  of  the  trochlea  within  the  joint 
cavity.     On  the  outer  side  the  capsule  is  attached  to  the  rounded  surface 


Fig.  6. — Trochlea,  capitellum,  epitrochlea,        Fig.    7. — Attachment   of  capsule   of  elbow- 
and  epicondyle.  joint  to  humerus,  from  the  front. 


of  the  external  cond\  le,  bringing  a  small  portion  of  the  epicondyle  within 
the  joint  cavity.  Posteriorlv  the  capsule  is  attached  across  the  upper 
part  ot  the  olecranon  tossa  (Fig.  5),  which  is  thus  mostl}' intra-articular. 
To  the  ulna  the  capsule  is  attached  shortly  below  the  tips  of  the  coronoid 
and  olecranon  processes,  leaving  these  portions  of  the  ulna  within  the 
joint  cavity,  to  be  received  in  the  fossa?  of  corresponding  name  in  the 
humerus  (Fig.  5).  Laterally  the  capsule  is  attached  close  to  the  margins 
of  the  greater  sigmoid  cavity  of  the  ulna.  The  upper  radio-ulnar  joint 
is  a  diverticulum  from  the  elbow-joint,  formed  between  the  circumference 
ot  the  head  of  the  radius  and  the  lesser  sigmoid  cavity  of  the  ulna.  The 
capsule  of  the  elbow-joint  is  attached  to  the  radius  below  the  orbicular 
ligament  which  surrounds  the  neck  of  this  bone. 


24  FRACTURES  OF  THE  ELDOIV 

Ligaments. — The  capsular  ligaiiifut  is  strongest  where  re-intorced  at 
the  two  sides  by  the  lateral  ligamciils.  If  the  capsule  is  cut  away  except 
where  re-inforced  in  this  way,  the  bones  of  the  forearm  and  the  humerus 
are  still  firmly  united,  and  still  only  the  normal  antero-posterior  motions 
are  possible.  The  internal  lateral  ligament  passes  as  two  bands  from 
the  epitrochlea  to  the  inner  surface  of  the  olecranon  and  coronoid  pro- 
cesses of  the  ulna;  the  tendon  of  origin  of  the  flexor  muscles  of  the  fore- 
arm is  so  firmly  attached  to  it  that  it  can  with  difficult\  be  dissected 
free.  The  external  lateral  ligament  arises  from  the  epicondyle  and 
spreads  out  in  two  branches  which  embrace  the  head  of  the  radius, 
blending  with  its  orbicular  ligament,  and  being  inserted  with  it  into  the 
margins  of  the  lesser  sigmoid  cavity  of  the  ulna.  The  supinator  (brevis) 
muscle  is  densely  adherent  to  the  external  lateral  ligament.  A  further 
band  of  fibres  passes  obliquely  across  the  anterior  part  ot  the  capsule 
from  the  epitrochlea  to  blend  with  the  orbicular  ligament  of  the  radius 
(Fig.  II). 

Limitation  of  Motion  in  the  Elbow-joint. — I  inxestigated  the  range  of 
motion  in  50  normal  elbows  of  children  (29  bo\s,  21  girls)  less  than 
fifteen  years  of  age  (average  age,  nine  and  one-tenth  years).  The  limit 
of  flexion  varied  from  14  degrees  to  40  degrees,  the  average  flexion  being 
3 1. 1  degrees;  the  limit  of  extension  varied  from  170  degrees  to  210 
degrees  (/.  e.,  30  degrees  hvperextension),  the  average  extension  being 
186.98  degrees,  or  nearly  7  degrees  of  hyperextension  beyond  a  straight 
line  (180  degrees).  In  girls  the  average  was  i86.g  degrees;  in  boys 
it  was   186.89  degrees. 

Flexion  is  resisted  first  by  contact  of  the  soft  parts  and  tension  on  the 
posterior  branches  of  the  lateral  ligaments  (Fig.  8);  then  b\-  the  mipinge- 
ment  of  the  coronoid  process  upon  the  coronoid  fossa,  and  to  a  slight 
degree  by  the  contact  of  the  radial  head  with  the  radial  fossa  (Fig.  11). 

Extension  is  limited  by  tension  on  the  anterior  bands  of  the  lateral 
ligaments  (Fig.  9)  and  on  the  anterior  capsule  (Fig.  10);  by  tension 
on  the  overlying  muscles,  especialh'  the  brachialis  anticus  and  biceps; 
also  by  the  tip  of  the  olecranon  striking  the  olecranon  fossa.  The  radial 
head  does  not  pass  posterior  to  the  axis  of  the  humerus  (Fig.  12).  The 
moderate  normal  hyperextension  present  in  the  elbow,  as  in  other  hinge 
joints  {e.  g.,  the  knee),  exists  for  the  purpose  of  increasing  the  stability 
of  the  extended  position.  If  extension  normally  stopped  at  180  degrees 
or  less,  the  elbow  when  extended  would  be  in  constant  danger  ot  col- 
lapsing like  a  knife-blade  into  its  sheath  whenever  the  voluntar\-  extending 
force  of  the  triceps  ceased  to  exert  its  influence.  By  allowing  slight 
hyperextension,  however,  a  position  of  relative  stability  is  secured,  even 
when  voluntary  action  (muscles)  is  not  being  exercised;  the  relation  of 
forearm    to    arm    being   maintained    then    b\-    ligaments    alone.     If  the 


ANATOMY 


25 


Fig.  8. — Kii;ht    elbow  Htxed,  to    show   tension    on    posterior    branch    of  internal 

lateral  ligament. 


Fig.  9. — Right  elbow  extended,  to 
show  tension  on  anterior  branch  of 
internal  lateral  ligament. 


Fig.   10. — Left  elbow  extended,  showmg 
tension  on  anterior  ligament. 


26 


FkACTUliES  OF  THE  ELROfF 


movement  of  extensif)n  is  carried  forcibly  beyond  the  normal  limit,  into 
marked  h)  perextension,  either  the  Hgaments  or  the  bones  must  break. 
In  adults,  whose  bones  are  much  stronger,  dislocation  usually  occurs, 
resulting  from  rupture  of  the  anterior  ligament  and  the  anterior  bands 
of  the  lateral  ligaments,  especially  of  the  internal  lateral,  on  which  the 
greater  strain  is  exerted,  owing  to  the  existence  of  the  carrying  angle 
(see  below);  or  the  epitrochlea  may  be  torn  off.  In  children  the  bones 
are  weaker  than  the  ligaments,  and  the  lower  end  of  the  humerus  is 
frequenth'  torn  of!  in  this  manner. 


WM 

w  ^1^ 

m 

Fig.  II. — Bones  of  left  elbow  in  hyperflexion,      Fig.  12. — Bones  of  right  elbow  in  exten- 
viewed  from  outer  side.  sion,  viewed  from  outer  side. 


The  position  of  greatest  stahihty  is  that  of  h\perflexion  (flexion  as  acute 
as  possible).  In  this  position  the  action  of  the  forearm  as  a  lever  is 
abolished.  Whenever  it  is  desired  to  use  the  forearm  as  a  lever  in  rotat- 
ing the  humerus  (as  in  H.  H.  Smith's  and  Kocher's  methods  of  reducing 
dislocations  of  the  shoulder),  the  forearm  is  flexed  at  right  angles  with 
the  arm;  and  as  the  forearm  is  moved  the  motion  is  transmitted  to  the 
humerus  by  means  of  the  lateral  ligaments  of  the  elbow.  In  any  case 
of  fracture  of  the  lower  end  ot  the  humerus,  and  especialh'  in  transverse 
fractures  above  the  condyles,  the  slightest  motion  of  adduction  or  abduc- 
tion imparted  to  the  forearm  will  likewise  be  transmitted  to  the  humerus, 
hut  will  cause  rotation  only  of  the  lower  fragment  of  the  humerus,  thus 


ANATOMY 


27 


easily  producing  motion  at  the  seat  of  fracture  and  distorting  the  relation 
of  the  fragments.  In  the  position  of  hyperflexion  this  lever  action  is 
abolished,  as  the  axes  of  the  forearm  and  arm  more  nearly  coincide. 
It  is  true  that  in  full  extension  the  axes  of  the  forearm  and  arm  nearly 
coincide,  and  that  leverage  for  rotation  of  the  humerus  is  absent;  but 
in  full  extension  the  forearm  acts  as  a  powerful  lever  in  adducting  or 
abducting  the  humerus  to  or  from  the  body,  and  if  any  fracture  of  the 
humerus  exists,  the  nearer  it  is  to  the  elbow  the  more  easily  will  the 
position  of  the  lower  fragment  be  influenced  by  adduction  or  abduction 
of  the  forearm  (Fig.  13). 


Fig.   13. — Action  of  forearm  in  extension,  to  adduct  or  abduct  lower  fragment  in 
fracture  of  lower  end  of  humerus. 


In  the  position  of  hyperflexion  the  triceps  acts  as  a  natural  splint  to 
the  lower  end  of  the  humerus,  being  tense  and  closely  applied  to  the 
body  of  the  bone,  covering  the  posterior  portions  of  the  condyles  and 
being  continued  around  beneath  the  joint  to  spread  out  over  the  ulna 
in  a  broad  fibrous  aponeurosis  (Fig.  58). 

Carrying  Angle. — In  the  above  series  of  50  cases,  the  carr\  ing  angle 
varied  from  162  to  178  degrees,  the  average  being   169.32  degrees.     In 


28 


l-R.ICTURES  OF  THE  ELBOW 


one  case  (a  woman  over  forty  years  of  age),  not  included  in  tlie  series, 
1  found  the  carrying  angle  140  degrees  in  each  elliow;  as  she  had  never 
suffered  any  injury  or  disease,  it  is  probable  that  the  cubitus  valgus  was 
due  to  rachitis  in  childhood.  The  carr\ing  angle  in  girls  averaged  168 
degrees;  in  boys  the  average  was  170.24  degrees.  This  shows  that  even 
before  puberty  girls  have  a  greater  deviation  of  the  forearm  from  the 
axis  of  the  humerus,  anticipating  the  greater  breadth  ot  the  pelvis  in 
adult  life. 

riie  carr\  uig  angle  is  not  formed  solcK,  as  is  sometimes  supposed, 
by  a  deviation  from  the  transverse  ot  the  lower  articular  surface  of  the 
humerus  (page  20);  there  is  also  a  similar  deviation  in  the  upper  articular 
surface  of  the  forearm  in   relation   to  its  longitudinal  axis.     Assuming 


a 


Fig.   14. — Diagram  of  carrying  angle. 
(After  Potter.) 


Fig.   15. — Erroneous  conception  of 
carrying  angle. 


that  the  carr\ing  angle  is  170  degrees,  we  have  a  deviation  of  10  degrees 
from  the  straight  line  (180  degrees)  to  account  for.  Distributing  this 
equally  between  the  arm  and  the  forearm  at  the  elbow,  we  obtain  the 
accompanying  diagram  (Fig.  14),  modified  from  Potter,  which  shows  the 
forearm  making  with  the  arm  an  angle  of  170  degrees  (85  degrees  + 
85  degrees),  open  externally,  a  b  being  the  line  of  the  elbow-joint.  Were 
the  entire  10  degrees  requisite  to  form  the  carr\  ing  angle  subtracted  from 
the  humerus,  we  should  have  the  result  shown  in  Fig.  15.  The  important 
difference  between  these  fig-ures  is  that  on  tolding  them  along  the  line 
a  b  (the  elbow-joint),  the  two  portions  of  the  diagram  would  be  super- 
posed in  Fig.  14,  whereas  in  Fig.  15  they  would  cross.  Now,  it  is  well 
known  that  in  h)'perflexion  the  forearm  normally  is  superposed  on  the 


ANATOMT 


29 


-ami,  anil  that  it  does  not  cross  its  axis  tf)  cotne  ni  contact  with  the 
chest.  Figs.  i6  and  17  are  from  photographs  ot  a  patient  with  a  normal 
right  elbow,  but  with  an  old  fracture  of  the  left  elbow,  which  had 
healed  with  gunstock  deformity.  The  change  here  has  been  the  loss  ot 
the  outward  obliquit\  ot  tlie  lower  articular  surface  ot  the  humerus; 
the  lower  articular  surtace  of  the  humerus  in  this  patient's  lett  arm  is 
appro.ximatelv  at  a  right  angle  with  the  long  a.xis  of  the  bone,  so  that 
when  he  flexes  his  forearm  it  does  not  become  superposed  on  the 
humerus,   as    in    the    normal    right    arm,   hut    crosses    its    axis   and    lies 


Fig.  16. — Patient,  showing  normal  carry-  Fig.  17. — Same  patient,  witli  both  elbows 

ing  angle  on  right,  and  gunstock  detormitv      flexed,    showing    deviation    of    left    forearm 
on  left.  from  sagittal  plane. 


against  the  chest  (Fig.  17).  This  question  is  of  the  utmost  importance 
in  the  endeavor  to  preserve  the  carr\ing  angle  while  treating  tractures 
of  the  lower  extremit\  ot  the  humerus  in  the  position  of  h\  perflexion. 
If  the  torearm  be  brought  up  in  such  a  manner  that  its  axis  coincides 
with  that  of  the  humerus,  the  carr\ing  angle  will  be  maintained;  and 
with  due  regard  to  this  point  it  is  not  necessary  to  have  the  torearm 
fully  extended  to  assure  one's  self  that  gunstock  deformity  will  not 
result. 


30  FRACTURES  OF  THE  FLllOfF 


DEVELOPMENT  OF  THE   LOWER  EPIPHYSIS  OF  THE  HUMERUS. 

For  clinical  purposes  there  is  no  better  way  to  approach  this  subject 
than  by  studying  a  series  of  skiagraphs  of  normal  elbows.  At  birth  the 
ends  of  all  three  bones  forming  the  elbow-joint  (humerus,  radius,  ulna) 
are  entirely  cartilaginous,  and  in  skiagraphs  seem  to  be  separated  by 
a  considerable  area,  since  cartilage  is  pervious  to  the  Rontgen  rays. 
The  shaft  or  (lifiphysis  of  each  of  these  bones  seems  in  the  skiagraph  to 
have  its  end  rounded  off,  being  devoid  ot  the  prominences  which  are 
characteristic  of  the  adult  bone.  One  by  one  new  shadows  appear  in 
the  clear  area  occupied  b\'  the  cartilaginous  ends,  as  bone  salts  are 
deposited  in  the  epiphyses.  The  clear  area,  composed  of  cartilage, 
which  still  separates  these  newly  developed  shadows  {epiphyseal  centres) 
from  the  diaphysis  or  shaft  of  the  bone  to  which  the  epiphyseal  centres 
belong,  is  called  the  epiphyseal  hue.  It  is  well  to  bear  clearly  in  mind 
the  relation  of  diaphysis,  epiphyseal  hue,  and  epiphyseal  centre,  as 
constant  use  will  be  made  of  these  terms. 

The  epiph\seal  centres  around  the  elbow  appear  in  the  following 
order: 

1.  Capitellum  of  humerus  in  first  halt  year  ot  life. 

2.  Head  of  radius  during  the  sixth  \ear. 

3.  Epitrochlea  about  six  years  ot  age. 

4.  Trochlea  during  the  eleventh  year. 

5.  Olecranon  later  in  the  eleventh  year. 

6.  Epicondyle  in  tweltth  \ear.  This  centre  frequenth'  cannot  be 
detected. 

The  three  tirst-named  are  the  most  constant  in  the  date  ot  their  appear- 
ance. 

Fig.  18  represents  the  normal  left  elbow  of  a  child  considerably  less 
than  one  year  old.  The  humerus  is  viewed  antero-posteriorly,  as  if  seen 
from  behind,  and  the  forearm  is  pronated.  It  will  be  noted  that  the 
lower  end  of  the  humerus  is  symmetrical  in  outline,  and  that  it  would 
be  impossible  to  tell,  without  looking  at  the  upper  end  of  the  bone,  at  the 
forearm,  or  at  tlie  relation  of  the  humerus  to  the  body,  which  was  the 
medial  and  which  was  the  lateral  side  ot  the  bone.  The  coronoid  and 
olecranon  fossae  are  indicated  by  the  lighter  area  in  the  centre  of  the 
lower  end  of  the  diaphysis.  A  considerable  clear  space  separates  the 
humerus  from  the  bones  of  the  forearm;  this  space  is  occupied  by 
cartilage,  which,  of  course,  is  pervious  to  the  Rontgen  rays,  and  pro- 
duces no  shadow  on  the  plate.  The  only  shadows  cast  are  those  of  the 
diaphyses  of  the  humerus,  radius,  and  ulna.  Note  that  the  coronoid  and 
olecranon  fossce  are  in  the  diaphysis;    the  lighter  shadow  cast  b}'  these 


THE  LOWER  EPII'IDSIS  OE  THE  HUMERUS 


31 


fossae  is  a  valuable  landmark,  and  is  of  iiiiportance  in  tin-  diagnosis  of 
epiphyseal  separations. 

Fig.  19  is  a  nearly  transverse  view  of  the  elbow  of  a  child  one  year  of 
age.  The  large  clear  cartilaginous  space  between  the  humerus  and 
forearm  still  exists,  and  the  jirohle  view  of  the  olecranon  and  coronoid 
foss;e  gives  the  appearance  of  two  wavy  lines  which  con\erge  and  almost 
touch  just  above  the  lower  limit  of  the  diaph}sis  ot   the  humerus,  but 


Fig.  18. — Skiagraph  showing  lower  epiphysis  of  humerus  in  first  half  year  (antero-posterior). 


again  diverge  as  this  border  is  reached.  Just  below  the  diaph\sis  of 
the  humerus,  in  the  region  occupied  by  the  hitherto  entirely  cartilaginous 
epiphysis,  can  be  detected  the  round  shadow  cast  by  the  epiphyseal 
centre  for  the  capitelhun  of  the  humerus.  This  is  the  first  portion  of  the 
epiphysis  in  which  bone  salts  are  deposited  with  sufficient  density  to 
cast  a  shadow;  it  is  the  first  centre  to  appear;  and  in  my  experience 
it  has  always  been  visible  in  skiagraphs  of  children  twelve  months  of 
age  or  older.  Dwight  is  almost  the  onl\  authorit\'  who  admits  that  this 
centre  appears  earlier  than  the  end  ot  the  second  year. 


32 


FRACTURES  OF  THE  ELIiOlf 


Fig.  20  shows  the  normal  left  elbow  in  antero-posterior  view,  seen 
from  behind,  at  the  age  of  three  years.  The  centre  for  the  capitelkim 
of  the  humerus  is  considerably  larger,  but  so  far  no  other  centre  is  visible. 
Fig.  21  shows  a  nearly  lateral  view  of  the  elbow  at  the  age  of  five  years; 
the  centre  for  the  capitelluni  is  still  the  only  one  visible.  The  converging 
lines  which  indicate  the  olecranon  and  coronoid  foss;e  are  plainly  seen. 

Fig.  22  is  an  antero-posterior  view  of  the  normal  right  elbow,  seen 
from  in  front,  at  the  age  of  five  years  and  eleven  months.  In  addition 
to  the  centre  for  the  capitellum,  two  other  centres  have  now  appeared; 


Fig.   19. — Skiagraph  showing  lower  epiphysis  at  about  one  year  of  age  (lateral). 

the  second  to  become  visible  (never  before  the  age  of  five  years)  is  that 
for  the  head  of  the  radius;  very  faintly,  also,  may  be  detected  the  centre 
for  the  epitrochlea  (internal  epicondyle),  which  is  invariably  the  third 
centre  to  appear.  Comparing  this  figure  with  Fig.  20,  it  will  be  seen 
that  the  diaphyses  of  the  humerus  and  ulna  both  have  grown  consider- 
ably, since,  whereas  in  Fig.  20  there  was  quite  an  interval  between  them, 
in  Fig.  22  (nearly  three  years  later)  their  shadows  overlap  each  other 
(see  also  page  80). 

Fig.  23  shows  the  elbow  at  eleven  \ears  of  age.     It  is  an  antero-posterior 
view  of  the  right  elbow,  seen  from  in  front.     The  centre  for  the  capi- 


THE  LOWER  EPIPIIVSIS  OF  THE  HUMERUS 


33 


Fig.  20. — Skiagraph  showing  lower  epiphysis  at  three  years  of  age  (antero-posterior). 


Fig.  21. — Skiagraph  showing  lower  epiphysis  at  five  years  (lateral 


34 


FR.ICT[:RES  OF  THE  ELROII' 


tellum  lias  ac(|uirecl  almost  achilr  proportions.  The  centre  for  the  head 
of  the  radius  has  its  t\pical  ap|")earance — that  of  a  coin  seen  from  the  side. 
The  centre  for  the  epitrochlea  is  now  quite  distinct;  and  a  new  centre 
is  just  discernible — that  tor  tiie  trochlea — seen  as  a  faint  shadow  close 
below  the  diaphysis  of  the  humerus,  between  the  shadows  of  the  epi- 
trochlea and  ulna.  Fig.  24  is  a  lateral  view  of  the  same  elbow  as  that 
shown  in  Fig.  23;  the  centre  for  the  capitellum  and  that  for  the  head 
of  the  radius  are  clearly  seen;  the  other  centres  cannot  be  distinguished 
in  a  lateral  view. 

In  Fig.  25  is  shown  a  side  view  of  the  elbow  of  a  bo\'  past  ten  years 
of  age;    the  centre  for  the  capitellum  and  that  for  the  head  of  the  radius 


Fig.  22. — Skiagraph  showing  lower 
epiphysis  at  five  years  and  eleven 
months  (antero-posterior). 


Fig.  23. — Skiagraph  showing  lower  epiphysis 
at  eleven  years  (antero-posterior). 


are  clearly  seen,  also  that  for  the  tip  of  the  olecranon,  which  often  does 
not  appear  so  soon.  It  is  important  to  note,  what  is  demonstrated  well 
in  these  lateral  views,  that  the  radius  lies  on  a  higher  plane  than  does 
the  ulna  (Allis);  this  will  be  referred  to  again  when  discussing  the  treat- 
ment of  fractures  m  this  region. 

Fig.  26  shows  the  elbow  during  the  twelfth  \ear.  In  addition  to  the 
centres  for  (i)  the  capitellum,  (2)  head  of  the  radius,  (3)  epitrochlea, 
(4)  trochlea  (all  of  which  are  more  developed  and  closer  to  their 
diaphyses  than  in  Fig.  23),  there  is  also  clearly  shown  in  this  figure  the 


THE  LOWER  EPIPHYSIS  OP  TPIE  PIUMERUS 


35 


centre  tor  the  epicondylc  (external  e|iiconcl\  lej,  just  at  tlie    level  ot    the 
epiphyseal  litie,  on  the  outer  side  ot  the  loint. 


Fig.  24. — Slviagrapli  of  lower  cpiplivsis  at  eleven  years  (lateral). 


Fig.  25. — Skiagraph  of  lower  e|iiplivsis  during  eleventh  )ear  (lateral). 


36 


FRACTURES  OF  THE  ELBOfF 


Fig.  27  shows  tile  elbow  at  twelve  years  and  three  months.  The  view 
is  not  quite  antero-posterior,  but  slightly  oblique.  The  obliquity  accounts 
for  the  prominence  of  the  capitellum.  In  addition  to  the  epiphyseal 
centres  seen  in  the  last  figure  (capitellum,  head  ot  radius,  epitrochlea, 
and  trochlea),  the  centre  tor  the  olecranon  process  of  the  ulna  is  visible 
(compare  Fig.  25),  above  the  body  of  the  ulna,  and  seen  through  the 
shadow  of  the  humeral  diaphysis,  just  to  the  lateral  (radial)  side  of  the 
centre  for  the  epitrochlea.  Usually  the  centre  for  the  olecranon  appears 
in  the  eleventh  year. 

Fig.  28  (aged  thirteen  years,  ten  months  and  a  half)  shows  close 
approach  to  the  adult  type,  though  the  epiph\  seal  lines  are  still  indicated. 
The  epicond\  le  appears  to  be  fusing  with  the  capitellum,  and  this  latter 


Fig.    26. — Skiagriiph     of     lower     epiphysis  Fig.  27. — Skiagraph  of  lower  epiphysis 

during  twelfth  year  (antero-posterior).  at   twelve   years    and   three    months  (ob- 

lique). 

has  alread\'  fused  with  the  trochlea.  These  centres  usualh'  unite  with  the 
diaphysis  about  the  age  of  fifteen  years,  while  that  for  the  epitrochlea 
remains  distinct  from  them,  and  does  not  unite  with  the  shaft  until  the 
eighteenth  vear.  This  fact,  together  with  other  influences  to  be  discussed 
presently,  accounts  for  the  relative  frequency  of  detachment  of  the 
epitrochlea  as  an  isolated  injur\'. 

Fig.  29  (aged  fifteen  years  and  two  months)  is  from  the  oldest 
subject  I  have  been  able  to  procure  in  whom  an\-  indication  of  an 
epiphyseal  line  remains.  The  line  between  the  epitrochlea  and  the 
diaphysis  is  still  distinct,  while  the  rest  of  the  epiph\seal  line  is  almost 
obliterated. 


CLASSIFICATION 


37 


CLASSIFICATION. 

On  account  of  the  irrcgularit\  of  tlie  articular  surface  of  tlie  lower 
entl  of  the  liumerus,  tlie  variety  of  fractures  encountered  is  large;  and 
the  complexity  of  the  development  of  tlie  epiphysis  adds  to  the  orthotlox 


Fig.  28. — Skiagraph  of  lower  epipliysis 
at  tliirteen  years,  ten  montlis  and  a  half 
(an  tero- posterior). 


Fig.  29. — Skiagraph  of  lower  epiphysis  of 
humerus  at  fifteen  years  and  two  months 
(antero- posterior). 


Fig.  30. — Diagram  to  show  classification  of  fractures  (modified  from  Kocher). 

fractures  a  number  of  cpipJiyscal  separations  whose  symptoms  and 
clinical  course  so  closeh'  resemble  those  of  the  corresponding  fractures 
that  it  is  not  worth  while  to  consider  them  apart. 


38  FR.ICTURES  OF  THE  ELBOIF 

The  acc()mpan\  ing  diagram  (Fig.  30),  modified  from  Kocher,  shows 
the  lines  of  tlie  principal  fractures.  The  nomenclature  emplo}ed  by 
writers  of"  different  nationalities  is  not  uniform,  bur  1  have  adopted  the 
following,  which,  though  not  that  customary  in  Knglish  works  on  surgery, 
has  the  merit  of  simplicit\': 

1.  Supracondylar.        1 

2.  Diacond\  lar.  [■  These  three  are  the  most  frequent  varieties. 

3.  External  condyle.  J 

4.  Separation  of  entire  lower  epiphysis. 

5.  Internal  condyle. 

6.  Intercondylar,  T  or  Y. 

7.  Trochlea. 

8.  Epitrochlea. 

9.  Epicondyle. 
10.  Capitellum. 


TABLE    SHOWING   THE    RELATIVE    FREQUENCY   OF    VARIOUS    FRACTURES    OF 
THE    LOWER    END    OF   THE    HUMERUS. 

Type.  J  £  oo'S-^st  .£  ^  M 

1.  Supraconii\iar(inclu(Jingdiacondylar)  29  40  13  39  78  13         39         36 

2.  External  cond}le 12  28  16  15  51  14  11          23 

3.  Epitrochlea 3  5  3  13  3^  6  10           7 

4.  Epiphyseal  separation        ....      7  29  .  .  .  .  3 

5.  Internal  condyle 4'  2  .  .  2  i  6' 

6.  Intercondylar i  2  ..  ..  2  2 

7.  Trochlea 

8.  Epicondyle .  .  .  .  .  .  3 

9.  Capitellum .  .  .  .  .  .  .  .  4 

Supracondylar  fractures  are  those  in  which  the  line  of  fracture  passes 
nearh'  transverseh'  across  the  humerus  from  epitrochlea  to  epicondyle. 
They  should  be  distinguished  from  fractures  of  the  lower  third  of  the 
humerus  (Fig.  31),  which  in  some  books  are  still  figured  as  supracondylar 
fractures.  Fig.  32  shows  a  typical  supracond\lar  fracture;  in  the  vast 
majority  of  cases  the  line  of  fracture  is  higher  on  the  posterior  than  on 
the  anterior  surface  of  the  humerus,  and  the  lower  fragment  is  displaced 
posteriorly.  Such  a  displacement  has  been  described  by  Kocher  as  a 
fracture  by  extension,  as  the  in)ur\-  usualh'  is  received  with  the  elbow 
extended,  and  the  fragment  is  displaced  toward  the  extensor  surface. 
In  very  rare  cases  the  line  of  fracture  runs  from  the  anterior  surface  of 

'  Diagnosis  uncertain  in  2  cases. 


CLASSII'ICATION 


39 


the  luiinerus  dovviivvarcl  and  backward,  and  the  lower  fragment  is 
displaced  forward,  into  the  bend  of  the  elbow  {" fracture  by  flexion" 
— Kocher),  as  shown   in    Fig.  ^^.     Mouchet  saw  this  displacement  only 


Fig.  31. — Skiagraph  of  fracture  of  lowtr  thiij  uf  humerus  (lateral). 


Fig.  32. — Skiagraph  of  supracoiKi\lar  fracture  (lateral). 


40 


FRACTURES  OF  TFIF  EI.BOH' 


Fit;.   :J3. — Skiagraph  of  supracondylar  fracture-  bv  '"flexion"  (lateral). 


Fig.  34. — Skiagraph  of  diacondylar 
fracture  (an tero- posterior). 


Fig.  35. — Skiagraph   of  diacondylar 
fracture  (antero-posterior). 


CLASSIFICATION 


41 


once  among  "8  supiaconcKlar  fractures,  in  his  sixt\-seconcl  case;   1  have 
never  encountered  it  m  a  recent  case. 

Diacondylar  fracture  is  a  term  emploved  by  Kocher  to  describe  a  more 
or  less  transverse  fracture  passing  through  the  condyles,  that  is,  below 
the  line  of  supracondylar  fracture  but  yet  above  the  epiphyseal  line. 
This  type  ot  fracture  is  called  by  Stimson  a  low  supracond\  lar  fracture, 
but  as  it  is  distinctly  through  the  condyles,  not  above  them,  it  has  seemed 
better  to  adopt  Kocher's  term.  Many  writers  do  not  distinguish  it 
from   the   supracondylar  type,   and   in   some   instances  it  is   almost  like 


Fig.  36. — Diagram  ot  diacondylar  fracture  of  the  type  "Posadas."     (After  Ciiutio.) 


splitting  hairs  to  do  so.  Some  surgeons  (Scudder,  Eisendrath,  and 
others)  have  in  a  most  unaccountable  manner  confused  it  with  epiph\- 
seal  separations.  The  fracture  usualh'  crosses  the  olecranon  fossa 
(Figs.  34  and  35).  Sometimes  there  is  no  displacement  of  the  lower 
fragment,  but  it  usualh'  is  displaced  posteriorly  like  a  supracond\  lar 
fracture;  anterior  displacement  is  rare.  It  is  unusual  for  the  lower 
fragment  to  be  displaced  directly  either  forward  or  backward;  it  is  exceed- 


42  l-RACTLRES  OF  THE  ELBOIV 

ingly  prone  to  be  forced  also  either  inward  or  outward.  Chutro  has 
called  attention  to  an  unusual  type  of  diacondylar  fracture,  first  recog- 
nized in  190 1  as  a  distinct  type  by  the  late  Prof.  Posadas,  of  Buenos 
Aires,  and  now  generally  known  by  his  name.  It  consists  in  a  trans- 
verse diacondylar  fracture  by  flexion  (the  lower  fragment  being  dis- 
placed forward  into  the  bend  of  the  elbow)  complicated  by  a  posterior 
luxation  of  the  radius  and  ulna,  which,  if  not  replaced,  may  come  in 
time  to  form  a  false  joint  with  the  lower  end  of  the  upper  fragment 
(Fig.  36).  According  to  Chutro,  descriptions  of  lesions  probably  similar 
had  been  recorded  previously  by  Cruveilhier  (1829),  Dauvergne  (1873), 
and  by  Pitha  and  Billroth  (1873);  and  in  searching  through  several 
thousand  skiagraphs,  made  during  the  last  ten  years  or  more,  I  have 
encountered  three  or  four  examples  of  this  fracture  which  do  not  appear 
to  have  been  recognized  as  a  type.  All  the  cases  hitherto  recorded, 
so  far  as  1  am  aware,  have  recovered  with  elbows  ankylosed  in  nearly 
complete  extension,  and  apparentlv  have  not  attracted  particular  atten- 
tion until  operative  relief  of  this  ankylosis  was  contemplated.  This 
was  the  case  in  all  five  of  Chutro's  patients;  so  that  I  esteem  myself 
fortunate  in  having  seen  and  recognized  this  injury  as  an  acute  condi- 
tion in  Case  28,  and  in  having  secured  without  open  operation  the 
very  satisfactory  result  there  recorded.  The  accompanying  skiagraphs 
(Figs.  37  and  38)  show  the  t\pical  appearance  of  an  elbow  ankylosed 
as  a  result  of  this  fracture. 

Fractures  of  the  external  condyle  usually  detach  the  entire  outer  part 
of  the  lower  extremity  of  the  humerus,  the  line  of  fracture  passing  from 
above  the  epicond\  le  to  enter  the  joint  at  or  near  the  centre  of  the  troch- 
lear surface  of  the  humerus.      Figs.  39  and  40  show  two  t\pical  examples. 

Fractures  of  the  epitrochlea,  or  epiphyseal  separations  of  the  centre  for 
the  epitrochlea,  are  by  some  surgeons  called  fractures  of  the  internal 
condyle;  but  it  has  always  seemed  to  me  clearer  to  define  the  internal 
condyle  (as  at  page  21)  as  including  both  epitrochlea  and  trochlea,  thus 
making  it  correspond  to  the  analogous  part  of  the  femur.  Detachment 
of  the  epitrochlea  is  a  frequent  injury,  and  probably  often  passes  un- 
observed. A  typical  skiagraph  is  reproduced  as  Fig.  41.  This  lesion 
often  accompanies  posterior  dislocation  of  the  elbow-joint  as  seen  in 
Fig.  42. 

Separation  of  the  Lower  Epiphysis. — This  injury  may  occur  at  any  age 
up  till  the  time  (about  fifteen  to  seventeen  years)  when  the  epiphyseal 
line  disappears,  but  is  rare  after  twelve  or  thirteen  years  of  age.  It  is 
exceedingly  common  for  a  small  shell  of  the  diaph\sis  to  be  detached 
with  the  epiphysis,  as  seen  in  Fig.  43.  If  a  shell  of  bone  all  across  the 
diaphysis  is  detached,  the  injury  must  be  classed  as  a  diacondylar 
fracture.      If  no  portion  of  the  diaphysis  is  detached  the  line  of  separation 


c/.jss/FJc.rnoN 


43 


Fig.  37. — Skiagraph  of  diacondylar  fracture  of  the  type  "Posadas"  (hiteral). 


Jig.  38. — Skiagraph   of  diacondylar   fracture   of  the   type  "Posadas"  (nearly 

antero- posterior). 


44 


FRACTURES  OF  THE  ELBOlf 


Via.  39. — Skiagraph  of"  fracture  of  cxrcrnal  condyle;  left  elbow,  viewed  from  behind 

and  inner  side. 


Fig.  40. — Skiagraph  of  fracture  of  external  condyle  (oblique). 


CUSS/FIC.ITION 


45 


passes  directly  nloiig  the  epi physcal  hue  {cartilage),  and  liciice  will  not  be 
visible  in  a  skiagraph.  Under  slkH  circiirnstances  the  diagnosis  rests 
on  the  symptoms  alone,  or  on  the  displacement  of  the  \isihle  epiphyseal 
centres  as  seen  in  a  skiagraph  made  before  reduction  has  been  accom- 


FlG.  41. — Skiagraph  of  fracture  of  tpitroclilca   (antero-posterior). 


Fig.  42. — Skiagraph   of  fracture   of  epitrochlea    complicating   posterior   dislocation 

of  elbow  (lateral). 


46  FRACTURES  OF  THE  ELBOJV 

plislied.  I  have  no  doubt  that  many  injuries  to  the  elbow  which  in 
reaHty  are  epiphyseal  separations  are  overlooked  on  this  very  account, 
because  no  line  of  fracture  is  seen  in  the  skiagraph;  and  conversely  it 
is  true  that  many  cases  of  diacondvlar  fracture  are  wrongly  classed  as 
epiphyseal  separations,  because  the  surgeon  does  not  know  where  the 
epiphyseal  line  reallv  is. 


Fig.  43. — Skiagraph  of  separation  of  lower  epiphysis,  with  shell  of  bone  torn  off 
diaphysis  (antero-posterior). 

Fractures  of  the  Internal  Condyle. — By  this  term  I  mean  a  fracture  such 
as  that  shown  in  Fig.  44,  where  the  entire  inner  part  of  the  articular 
extremity  of  the  humerus  is  detached.  The  line  of  fracture  is  usually 
more  or  less  longitudinal,  corresponding  to  the  typical  fracture  of  the 
internal  cond\le  of  the  femur,  and  enters  the  joint  at  or  near  the  centre 
ot  the  trochlear  surface.  Fig.  45  shows  a  fracture  of  the  internal  condyle 
without  displacement. 


CLASSIFICATION 


47 


Fig.  44. — Skiagraph  of  fracture  of  intt-rnal  condyle  (antero-posterior 


Fig.  45. — Skiagraph  of  fracture  of  internal 
condyle  without  displacement. 


Fu;.  46. — Skiagraph  of  atypical  fracture  of 
lower  end  of  humerus  (antero-posterior). 


48 


FRACTURES  OF  THE  ELBOIC 


Intercondylar  Fractures. — These  are  fractures  which  separate  the  con- 
dyles from  each  other  and  from  the  shaft  of  the  humerus  as  well.  The 
line  of  fracture  thus  somewhat  resembles  a  Y  or  T.  They  are  generally 
acknowledged  to  be  rare  injuries,  and  I  am  inclined  to  believe  they  are 
much  more  unusual  than  generally  supposed.  In  studying  a  series 
of  several  thousand  skiagraphs  I  have  noticed  that  the  fracture  repre- 
sented in  Figs.  46  and  47  is  a  much  less  rare  injurw  and  that  it  commonly 
is  described  as  a  T-fracture.  This,  it  will  be  noticed,  it  is  not;  the  line 
of  fracture  (Fig.  46,  antero-posterior)  passes  transversely  through  or 
just  above  the  condyles,  and  the  lower  fragment  embraces  in  one  piece 


Fig.  47. — Skiagraph  of  atvpical  fracture  of  lower  end  of  humerus  (lateral). 

the  entire  epiphysis  and  the  lower  end  of  the  diaphysis;  the  second 
fragment  is  formed  by  a  splinter  of  the  shaft  above  the  internal  condyle, 
but  as  is  plainly  seen  in  the  lateral  view  (Fig.  47)  this  detached  fragment 
does  not  extend  to  the  articular  surface  as  it  would  do  if  composed  of 
the  internal  cond\le  itself.  I  ha\e  been  entireh'  unable  to  find  any 
skiagraph  showing  in  antero-posterior  view  a  true  mtercond\'lar  fracture.' 
The  nearest  approach  to  this  is  in  Case  56  (Fig.  150),  which  I  classed  as 
a  fracture  of  the  internal  cond\le  alone  until  the  skiagraph  showed 
there  was  also  a  fracture,  probably  impacted,  of  the  external  cond\le; 
in  this  patient  there  is  no  doubt  whatever  tliat  the  internal  cond\  le  was 


'  Since  writing   the   above   I   have   seen  one   case  where  the   skiagraph  confirmed  the 
diagnosis. 


CLASSIFICATION 


49 


fractured  into  the  joint,  and  that  the  external  condyle  also  was  fractured, 
although  impacted  into  and  not  detached  from  the  shaft. 

Fracture  of  the  Trochlea. — Isolated  detachment  of  the  trochlear  surface 
or  of  a  part  of  it  I  have  not  observed.  Stimson  gives  an  illustration  of 
a  case  under  his  care. 

Fracture  of  the  epicondyle  (external  epicondyle)  is  exceedingly  unusual, 
though  Mouchet  claims  to  have  recognized  it  three  times.  Gurlt  de- 
scribes two  extra-articular  fractures  of  the  epicondyle.  If  the  fragment 
detached  is  so  large  as  to  involve  the  joint  it  will  be  better  to  class 
the  fracture  with  those  of  the  external  condyle. 

Fracture  of  the  capitellum  is  the  least  unusual  of  these  rarer  fractures. 
Stimson  refers  to  a  number  of  cases.  Fig.  48  shows  a  partial  fracture 
of  the  capitellum  which  I  produced  experimentally  (see  page  52).  The 
fragment  detached  is  completely  intra-articular. 


Fig.  48. — Photograpli  of  expcriint;ntal  fracture  of  capitellum. 

Enumeration  of  these  typical  fractures  does  not  exclude  the  existence 
of  a  goodly  number  of  atypical  fractures.  These  usually  are  produced 
by  such  great  violence  as  to  be  compound  or  otherwise  complicated, 
and  therefore  do  not  come  within  the  limits  set  for  this  monograph. 


GENERAL  MECHANISM  BY  WHICH  FRACTURES  OF  THE  LOWER 
END  OF  THE  HUMERUS  ARE  PRODUCED. 


I.  In  falls  upon  the  outstretched  hand  the  force  is  transmitted  chiefly 
to  the  radius,  as  the  ulna  does  not  articulate  with  the  carpal  bones. 
From  the  radius  the  force  is  transmitted  directh'  to  the  external  condyle 
of  the  humerus,  the  head  of  the  radius  impinging  upon  the  capitellum 
(Fig.  49).  The  force  received  upon  the  hand  is  transmitted  to  the 
internal  condyle  only  by  first  reaching  the  ulna  through  the  medium  of 
4 


50 


FRACTURES  OF  THE  ELBOIV 


the  interosseous  ligament  (Fig.  49),  the  fibres  of  which,  passing  obhtjuely 
downward  from  the  radius  to  the  uhia,  are  well  adapted  to  distributing 
such  a  strain.  It  thev  ran  from  the  ulna  obli()uely  downward  to  the 
radius  such  a  distribution  of  the  force  would  be  impossible.  Falls  upon 
the  hand  are  very  rarely  followed  by  fractures  of  the  internal  condyle; 
they  usually  produce  a  fracture  of  the  external  condyle  alone,  or,  more 
frequently,  a  transverse  fracture  above  the  condyles.  The  elbow  usually 
is  more  or  less  extended  in  falls  upon  the  outstretched  hand;  in  most 
cases  it  is  fully  extended;  and  I  tliink  tlie  greater  frequency  of  supra- 
condylar fractures  as  compared  with  those  of  the  external  condyle  alone 


Fig.  49. — Mechanism  of  fracture  of  external  con(]\le  from  fall  on  hand. 

is  no  doubt  partly  due  to  the  action  of  the  anterior  ligament  and 
anterior  bands  of  the  lateral  ligaments,  which  tear  off  the  lower  ex- 
tremity of  the  humerus  when  hyperextension  follows  a  fall  on  the  out- 
stretched hand.  The  longitudinal  fibres  of  the  anterior  ligament,  passing 
from  above  the  coronoid  fossa  of  the  humerus  to  the  base  of  the  coronoid 
process  of  the  ulna,  are  strong  enough  to  stand  considerable  strain  with- 
out breaking;  and  they  are  re-inforced  bv  oblique  fibres  passing  from  the 
epitrochlea  to  the  orbicular  ligament  of  the  radius  (Fig.  10).  In  hyper- 
extension of  the  elbow  these  two  band-like  portions  of  the  anterior 
ligament  are  put  on  the  stretch,  and,  together  with  the  anterior  bands 


P.ITimCF.NF.SrS  51 

of  the  two  lateral  ligaments,  hold  the  forearm  very  firmly  in  contact  with 
the  humerus.  If  it  is  desired  to  rupture  these  bands,  as  in  producing  an 
experimental  dislocation  of  the  elbow  by  means  of  hypcrextension,  the 
hyperextension  must  be  gradually  and  carefully  done.  Sudden  hyper- 
extension  is  much  more  apt  to  cause  fracture. 

Of  course,  the  direct  thrust  from  the  fall  (transmitted  through  the 
radius  and  indirectly  through  the  ulna)  has  probably  even  more  to  do 
with  breaking  off  the  lower  end  of  the  humerus;  but  if  this  were  the 
only  cause,  anterior  displacement  of  the  lower  fragment  would  not  be 
so  rare.  For  as  the  articular  surface  of  the  humerus  is  on  a  plane  anterior 
to  the  long  axis  of  the  bone,  a  simple  upward  thrust  transmitted  from  the 
forearm  in  full  extension  would  be  more  apt  to  displace  the  lower  frag- 
ment forward  than  posteriorly.  So  that  it  seems  impossible  to  deny, 
as  has  been  done  by  Destot,  Vignard,  and  Barlatier,  the  important 
influence  of  the  ligaments  in  tearing  the  fragment  loose  as  the  elbow 
is  hyperextended  by  the  impact  of  the  hand  with  the  ground;  and  if 
this  be  admitted,  the  posterior  displacement  of  the  fragment  follows 
as  a  matter  of  course.  If  these  fractures  were  produced  by  falls  upon 
the  hand  with  the  elbow  flexed  at  a  right  angle  (which  they  are  not), 
then  the  theory  of  simple  thrust  would  have  to  be  admitted,  and  the 
posterior  displacement  without  leverage  by  hyperextension  could  be 
understood.  But  the  elbow  cannot  be  so  firmly  fixed  by  the  muscles 
as  to  remain  flexed  at  a  right  angle  (more  or  less)  when  the  patient 
falls  on  the  outstretched  hand;  the  elbow  is  either  violently  hyper- 
extended (as  in  the  mechanism  discussed  above),  or  it  suddenl}'  collapses, 
a  much  less  usual  sequel.  In  only  one  instance  (Case  50)  have  I  found 
a  distinct  injury  following  a  fall  on  the  hand  which  produced  acute  flexion 
of  the  elbow;  in  this  case  the  result  was  an  epiphyseal  separation.  In 
Case  II  the  production  of  a  supracondylar  fracture  by  pure  hyper- 
extension is  well  illustrated,  as  this  boy  did  not  fall  on  his  outstretched 
hand,  but  on  the  flexor  surface  of  his  fully  extended  forearm,  the  elbow 
being  thus  violently  hyperextended,  and  very  little  if  any  upward  thrust 
being  transmitted  to  the  humerus  from  the  forearm. 

The  greater  frequency  of  fractures  of  the  epitrochlea,  as  compared 
with  those  of  the  epicondyle,  may  also  be  accounted  for  by  the  theory 
of  ligamentous  distraction;  since  it  is  quite  evident,  owing  to  the  exist- 
ence of  the  carrying  angle,  that  in  falls  upon  the  hand  with  the  elbow 
extended  the  internal  lateral  ligament  receives  a  greater  part  of  the 
strain  than  the  external;  and  it  is  well  known  that  in  dislocations  of 
the  elbow  the  internal  lateral  ligament  is  more  widely  ruptured  than  the 
external,  in  spite  of  its  greater  strength.  The  existence  of  the  carrying 
angle  at  the  elbow  may  also  be  invoked  as  a  partial  explanation  of  the 
frequency  of  fractures  of  the  external  condyle  following  falls  on  the  hand, 


52 


FRACTURES  Of  THE  ELBOfV 


as  the  external  condyle  is  found  in  the  line  of  compression.  Force  ap- 
plied at  the  extremities  of  two  lines  joined  at  an  angle  tends  to  diminish 
that  angle  by  approximating  the  ends  ot  the  lines.  Thus  in  Fig.  50, 
if  force  acts  in  the  direction  of  the  arrows,  from  A  and  D,  the  line  AO 
will  much  more  readily  be  forced  into  the  pf)siti()n  BO  than  into  that  of 
CO.  The  mere  act  of  hvperextension  of  the  elbow,  produced  by  falls 
on  the  hand  when  the  elbow  is  already  fully  extended,  usually  causes 
more  injury  to  the  external  than  to  the  internal  condyle,  possibly  owing 
to  the  mechanism  suggested  in  Fig.  50.  In  producing  an  experimental 
dislocation  of  the  elbow  by  hyperextension,  I  succeeded  in  obtaining 
not  onl\-  the  fracture  of  the  capitellum  shown  in  Fig.  48,  but  also  a  split- 
ting fracture  of  the  head  of  the  radius;     both   these  injuries  evidently 


Fig.  50. — Diagram  of  fracture  of  external 
condyle  by  abduction  of  forearm. 


Fig.  51. — Diagram  of  fracture  of  external 
condyle  by  abduction  of  forearm. 


were  due  to  the  greater  injury  exerted  upon  the  outer  side  of  the  joint, 
owine  to  the  natural  tendency  of  all  force  transmitted  from  the  forearm 

o 

to  the  iiumerus  to  cause  increase  of  the  physiological  cubitus  valgus,  as 
indicated  in  Fig.  51. 

Thus  the  existence  of  the  carrying  angle  accounts  for  the  greater 
frequency,  after  falls  on  the  outstretched  hand,  of  fractures  ot  the  epi- 
trochlea  or  rupture  of  the  internal  lateral  ligament  as  compared  with 
detachment  of  the  epicondyle  or  rupture  of  the  external  lateral  ligament; 
and  in  part  for  the  greater  frequenc\-  of  fractures  of  the  external  condyle 
from  the  same  injury,  as  compared  with  fractures  of  the  internal  condyle. 
In  Case  9  a  sudden   increase  of  the  cubitus  valgus,  by  wrenching  the 


PATHOGENESIS 


53 


elbow  between  two  upright  bars,  resulted  in  a  partial  supracondylar 
fracture,  the  line  of  fracture  commencing  above  the  internal  condyle 
(on  the  side  of  extension  as  distinguished  from  the  side  of  compression) 
and  extending  nearly  all  the  way  across  the  shaft. 

2.   The   effects   of  falls   upon   the  flexed  forearm   or   upon   the   acutely 
flexed  elbow  are  perhaps  less  difficult  to  analyze.     If  the  patient  lands 


Fig.  52. — Diagram  of  action  of  force  in  causing  diacondyiar  fracture.    (After  Cliutro.) 


Fig.  53. — Skiagraph  of  fracture  of  olecranon,  external  condyle,  and  neck  of  radius. 


squarely  upon  the  upper  extensor  surface  of  the  ulna,  he  may  acquire 
a  fracture  of  the  internal  condyle,  the  impact  driving  the  ulna  against 
the  trochlea  and  splitting  the  entire  inner  condyle  off"  the  humerus;  but 
force  received  in  this  way  is  more  apt  to  expend  itself  upon  the  ulna, 


54 


IR.ICTURES  Oi    THE  ELBOfT 


fracturing  it  and  perhaps  producing  a  forward  dislocation  of  the  radius. 
If  the  patient  hinds  not  solelv  upon  tlie  subcutanetjus  portion  of  the 
upper  ulna,  but  upon  the  radius  as  well,  the  usual  result  is  a  transverse 
diacondylar  fracture,  with  little  displacement  (Fig.  52);  or  sometimes 
an  epiphyseal  separation  (Case  48).  It  has  been  claimed  that  falls 
upon  the  upper  part  of  the  ulna,  with  the  forearm  flexed  to  a  right  angle, 


Fig.  54. — Skiagraph  of  fracture  of  olecranon  and  supracondylar  fracture  "by  flexion." 

may  be  a  cause  of  fractures  of  the  external  condyle,  the  force  being 
transmitted  from  the  greater  sigmoid  cavity  of  the  ulna  to  the  outer 
lip  of  the  trochlea,  and  thus  detaching  the  external  condyle.  One  case 
in  my  series  (Case  36)  has  such  a  histor\';  but  it  seemed  to  me  that  the 
injury  was  more  likely  to  be  due  to  direct  violence,  the  fall  having  been 
on  the  outer  part  of  the  acutely  flexed  elbow,  rather  than  upon  the 
extensor  surface  of  the  flexed  forearm. 


PATHOGENESIS  55 

Falls  upon  the  acutely  flexed  elbow  mav  cause  fracture  of  either  concl\  le 
or  of  both  (supracondylar);  and  the  lower  fragment  of  the  humerus 
may  be  detached  in  one  piece  or  it  may  be  comminuted.  If  the  arm  is 
abducted  in  falling,  the  patient  will  land  more  upon  the  inner  surface  of 
the  elbow,  and  a  fracture  of  the  internal  condyle  will  result,  as  in  Cases 
53  and  55.  If,  on  the  contrary,  the  arm  is  held  close  to  the  side  in  falling, 
so  that  the  patient  lands  more  upon  the  outer  surface  of  the  elbow,  a 
fracture  of  the  external  condyle  may  result  (Case  36).  An  interesting 
result  of  a  fall  on  the  flexed  elbow  is  seen  in  Fig.  53;  here  there  were 
produced  fractures  of  the  olecranon,  of  the  external  cond}le,  and  of  the 
neck  of  the  radius.     A  supracondylar  fracture  "by  flexion"  usually  is 


Fig.  55. — Diagram  of  fracture  of  external  condyle  by  adduction  of  forearm. 


a 


V- 


■< 

Fig.  56. — Diagram  of  fracture  of  external  condyle  by  adduction  of  forearm. 

produced  in  the  same  way,  the  olecranon  process  carrying  the  lower 
fragment  of  the  humerus  forward  into  the  bend  of  the  elbow.  Fig.  54 
shows  such  a  fracture  higher  on  the  diaph\sis  than  typical,  and  accom- 
panied by  fracture  of  the  olecranon  without  displacement. 

3.  Still  another  injury  may  occur,  the  force  being  applied  directly 
to  the  outer  side  of  the  fully  extended  joint,  which  is  crushed  between  the 
body  above  and  the  ground  beneath.  In  Case  8  such  an  injury  caused 
a  comminuted  supracondylar  fracture,  the  elbow  feeling  like  a  bag  of 
bones.  In  Cases  38  and  40  fracture  of  the  external  condyle  alone  was 
produced  in  this  way,  either  by  direct  violence  (rare)  or  by  adduction 
of  the  forearm,  the  shoulder  and  hand  coming  first  into  contact  with 
the  ground,  and  the  weight  of  the  body  then  forcing  the  elbow  (the  apex 
of  a  triangle,  as  in  Figs.  55  and  56)  into  a  straight  line.  Stimson  and 
others  have  frequently  produced  such  a  fracture  experimentally  by 
adduction  of  the  supinated  forearm.  Evidently  the  external  condyle 
is  torn  off  by  the  pull  of  the  external  lateral  ligament. 


56  FRACTURES  OF  THE  ELBOff 


EXAMINATION    OF    THE    PATIENT. 

It  is  necessary  in  the  first  place  to  insist  upon  the  surgeon  making 
an  inteUigent  and  exhaustive  examination  of  all  injuries  in  the  region 
of  the  elbow.  The  bad  results  seen  arise  almost  exclusively  from  failure 
to  recognize  the  injury,  and  hence  to  institute  proper  treatment,  when 
the  case  is  first  seen.  Too  often  a  patient  with  a  swollen  and  painful 
elbow  has  the  part  dressed  with  lead  water  and  laudanum  or  some 
patent  clay,  the  dressing  being  held  in  place  hv  a  bandage,  in  many 
cases  not  even  a  sling  being  applied.  After  some  ten  days  or  two  weeks 
it  is  noticed  that  as  the  swelling  subsides  the  elbow  remains  stiff,  and 
injudicious  attempts  at  massage  and  forced  passive  movements  make 
the  patient  miserable,  exasperate  the  mother,  and  usuall\-  dishearten 
the  surgeon.  The  fracture  was  not  reduced,  callus  is  forming,  arthritis 
persists,  and  the  fault  is  the  surgeon's  for  neglecting  proper  treatment  at 
the  proper  time.  As  Kocher  says,  "Man  hat  entweder  gut  reponirt  und 
bekommt  gute  Heilung,  oder  man  hat  schlecht  reponirt  und  bekommt 
schlechte  Heilung." 

History  of  the  Injury. — While  the  patient  is  being  prepared  for  examina- 
tion, the  surgeon  should  inquire  how  the  iniur\  was  received.  He  should 
learn  the  height  of  the  fall,  the  positions  of  the  arm,  elbow,  and  hand, 
and,  it  possible,  the  manner  of  lauding  ;  he  may  ask  about  the  position 
of  the  arm  when  first  seen  by  by-standers;  whether  the  bone  was 
heard  or  felt  to  crack  or  grit;  and  in  general  learn  everything  about 
the  injury  which  might  have  a  bearing  on  the  diagnosis.  As  will  be 
seen  subsequently,  definite  types  of  fracture  usually  result  from  certain 
injuries. 

Inspection. — I  make  it  an  invariable  rule  to  remove  all  the  patient's 
clothes  down  to  the  waist,  so  as  to  be  enabled  to  compare  the  appearance 
of  the  two  arms,  from  wrist  to  shoulder.  Note  the  position  of  the  fore- 
arm (pronation  or  supination);  of  the  elbow  (flexed  or  fully  extended); 
the  presence  or  the  absence  of  the  carr\ing  angle;  the  existence  of  abra- 
sions or  contusions  of  the  part  of  the  limb  said  to  have  come  into  contact 
with  the  ground.  Observe  the  presence  or  absence  of  swelling  around 
the  elbow,  its  character  and  localization;  whether  confined  to  the  region 
of  the  supinators,  to  the  extensor  surface  of  the  forearm,  extending 
along  the  flexor  group  of  muscles  arising  from  the  epitrochlea,  or  limited 
to  the  flexure  of  the  elbow.  Ecchymosis  and  bullae,  the  latter  of  which 
are  rare,  do  not  appear  usually  for  twent\-four  or  thirt\-six  hours  after 
the  injur;-;  and  if  the  fracture  is  reduced  prompth'  they  seldom  appear 
at  all.  Ask  the  patient  to  move  the  elbow  if  possible.  In  severe  injuries 
around  the  elbow  the  whole  upper  extremit\'  is  moved  from  the  shoulder 


EXAMINATION  OF  THE  PATIENT  57 

like  a  pump-handle,  the  elbow  itself  being  held  rigid.  Only  in  injuries 
of  extreme  degrees  does  the  elbow  become  flail-like. 

Palpation. —  It  is  always  well  to  go  from  the  known  to  the  unknown;  it 
is  frequently  useless  to  begin  by  palpating  bony  prominences  around 
the  elbow,  since  from  the  extent  of  the  swelling  it  may  be  impossible 
to  identify  them  in  this  way.  Unless  some  definite  method  is  followed, 
some  important  point  is  nearly  sure  to  be  overlooked.  It  is  often  well, 
especially  in  the  case  of  children,  to  gain  the  patient's  confidence  by 
examinins:  first  the  normal  elbow. 

In  palpating  the  injured  elbow,  I  divide  the  examination  into  two 
parts:  (i)  Palpation  with  the  finger  tips;  (2)  examination  for  crepitus, 
abnormal  mobility,  etc. 

1.  The  examination  witli  tfie  finger  tips  invariably  starts  by  running 
the  fingers  gently  but  firmh'  up  the  subcutaneous  border  of  the  ulna. 
This  can  invariably  be  found,  and  as  invariably  leads  to  the  olecrniiou, 
a  landmark  directly  at  the  elbow,  and  one  which  is  easily  distinguished 
from  either  condyle  when  located  in  this  manner.  The  second  step 
is  to  follow  the  radius  up  to  its  head,  and  to  identify  in  this  way  the 
external  condyle.  When  the  olecranon  and  the  external  condyle  have 
been  positively  identified,  it  is  scarcely  ever  difficult,  even  in  a  much 
swollen  elbow,  to  detect  the  internal  condyle,  which  normally  is  easier  to 
discover  by  palpation  than  is  the  external.  But  if  the  surgeon  commences 
his  voyage  of  discovery  in  the  midst  of  the  rocks  and  shoals  around  the 
elbow,  he  frequently  will  be  considerably  puzzled  to  decide  which  is 
internal  condyle  and  which  olecranon,  or  to  be  positive  that  the  radial 
head  and  the  external  condyle  bear  a  normal  relation  to  each  other. 

Having  identified  the  three  bony  landmarks  of  the  elbow  region,  the 
surgeon  must  study  their  relation  to  each  other.  If  this  relation  is  normal 
the  bones  of  the  forearm  are  not  dislocated  backward,  but  the  existence 
of  a  fracture  is  not  excluded;  if  this  relation  is  abnormal,  a  dislocation, 
a  fracture,  and  rarely  both,  may  be  present. 

Then  carefully  palpate  the  shaft  of  the  humerus  from  above  downward, 
as  far  as  possible.  In  this  way  it  is  often  possible  to  determine,  in  the 
presence  of  a  fracture,  that  the  upper  fragment  is  projecting  forward 
into  the  fold  of  the  elbow. 

Finally,  every  primary  examination  should  include  tests  for  paralysis 
or  anesthesia  from  injury  of  the  nerves  around  the  elbow,  especially 
the  ulnar  and  median  distribution  for  sensation,  and  the  radial  (musculo- 
spiral)  for  motion. 

2.  Examination  for  Crepitus,  Abnormal  Mobility,  etc. — Holding  the  shaft 
of  the  humerus  firmly  in  one  hand,  the  forearm  should  be  grasped  m  the 
other.  First  gentle  motions  of  flexion  and  extension  should  be  made. 
Then  the  forearm,  flexed  to  a  right  angle,  should  be  thrust  backward 


58  FRACTURES  OF  THE  ELBOW 

and  pulled  forward  on  the  humerus;  in  the  case  of  supracondylar  fracture 
(and  in  some  others)  the  lower  fragment,  moving  with  the  forearm, 
will  produce  crepitus  as  it  slides  back  and  forth  on  the  upper  fragment 
(shaft  of  the  humerus).  If  this  manoeuvre  fails  to  produce  crepitus  or 
to  reveal  abnormal  mobility,  the  shaft  of  the  humerus  should  be  grasped 
tightly  and  an  endeavor  made  to  rotate  the  lower  fragment  of  the 
humerus  on  the  upper,  using  the  bent  forearm  as  a  lever.  Attempts 
should  next  be  made  to  discover  the  presence  of  lateral  mobility  in  the 
elbow,  by  fully  extending  the  forearm  and  adducting  and  abducting 
it  while  the  humerus  is  held  rigid  with  the  other  hand;  this  test  usually 
is  positive  in  fractures  of  either  condyle,  as  well  as  in  most  supracondylar 
fractures,  while  the  earlier  tests  described  rarely  are  positive  except  in 
supracondylar  fractures. 

If  all  the  above  tests  give  a  negative  result,  or  in  cases  where  further 
confirmation  of  a  suspected  fracture  of  one  or  other  condyle  is  desired, 
the  surgeon  should  next  grasp  the  condyles  one  in  each  hand,  and  en- 
deavor to  elicit  crepitus  by  rubbing  them  together;  or  by  pressing  them 
together  and  suddenly  releasing  the  pressure,  sometimes  a  "tapping" 
sensation  may  be  felt.  If  these  final  tests  are  positive,  it  next  becomes 
necessary  to  prove  which  is  the  fractured  condyle.  This  is  done  by 
proving  that  the  other  remains  attached  to  the  shaft  of  the  humerus.  If 
neither  condyle  is  attached  to  the  shaft,  and  there  is  motion  between 
the  two  condyles,  it  is  safe  to  diagnosticate  an  intercondylar  (T  or  Y) 
fracture. 

It  may  be  thought  that  these  manipulations  and  this  somewhat  tedious 
examination  are  not  only  unnecessary  but  undesirable.  That  they  are 
necessary  is  best  proved  by  the  fact  that  even  with  the  most  painstaking 
and  methodical  examination  a  fracture  is  occasionally  overlooked,  either 
because  impacted,  or  because  the  detached  fragment  lies  entirely  within 
the  joint;  but  the  more  hasty  and  superficial  the  examination  the  more 
apt  will  other  fractures  be  to  go  undetected.  That  these  manipulations 
are  not  undesirable  follows  as  a  corollary  of  the  last  statement;  and  that 
they  are  actually  desirable  I  think  is  clear  when  it  is  pointed  out  that 
a  fracture  impacted  with  deformity  will  be  thus  released,  and  reduction 
more  easily  accomplished.  That  damage  can  be  done  by  rough  handling 
is,  of  course,  possible;  but  the  fact  that  no  damage  ensued  in  the  series 
of  56  cases  herewith  reported  is  certainly  evidence  that  such  an 
examination  as  advised  can  be  made  without  rough  handhng.  That  this 
examination  is  painful  to  the  patient  cannot  be  denied;  but  it  is  not 
so  painful  in  practice  as  it  appears  in  print,  and  the  paramount  impor- 
tance for  prognosis  of  making  a  positive  diagnosis  at  the  earliest 
possible  moment  more  than  compensates  the  surgeon  for  his  trouble 
and  the  patient  for  his  suffering;    for  if  an  accurate  diagnosis  is  made, 


EXAMINATION  OF  THE  PATIENT  59 

and  proper  treatment  proniptK-  instituted,  both  the  surgeon's  trouble 
and  the  patient's  suffering  will  he  short-li\ed;  whereas,  under  contrary 
circumstances  a  deformed  and  painful  elbow  will  long  remain  a  sorrow- 
ful memento  to  the  patient  and  an  opprobrium  to  the  art  of  surgery. 

The  question  of  the  use  of  a  general  anaesthetic  for  the  purposes  of 
diagnosis  and  for  reduction  of  the  fracture  is  naturally  raised  at  this 
point.  Many  surgeons  at  present  are  advising  it  as  a  routine  measure. 
For  mv  own  part  I  have  employed  it  in  onl\  three  cases  (Cases  8,  lo,  20) 
for  reducing  the  fracture,  and  never  solely  for  diagnosis.  These  three 
cases  were:  (Case  8)  a  badly  comminuted  supracondylar  fracture,  the 
elbow  feeling  like  a  bag  of  bones;  (Case  10)  a  diacondylar  fracture 
"by  flexion;"  and  (Case  20)  an  impacted  supracondylar  fracture,  the 
skiagraphs  showing  that  the  first  attempts  at  reduction,  without  an 
an.nesthetic,  had  not  been  successful. 

Interpretation  of  Skiagraphs. — Whenever  possible,  a  skiagraph  of  the 
elbow  should  be  made  after  the  surgeon  has  concluded  his  routine 
examination,  and  before  any  attempt  at  reduction  has  been  made.  It 
might  be  still  more  desirable  to  have  a  skiagraph  taken  before  any 
examination  whatever  were  made;  but  it  certainly  would  be  highly 
objectionable  for  the  surgeon  to  consider  a  physical  examination  un- 
necessary if  a  skiagraph  was  obtainable  before  one  was  made.  But 
it  is  desirable  to  have  an  ocular  demonstration  of  the  lesions  such  as  a 
skiagraph  gives,  if  possible  before  any  attempts  to  reduce  the  fracture 
are  made.  Unfortunately,  it  is  rarely  possible  to  secure  the  services  of 
a  skiagrapher  at  so  short  notice;  so  that  the  surgeon  must  base  his  tenta- 
tive diagnosis  and  guide  his  treatment  solely  by  the  eyes  wdiich  he  has 
in  the  ends  of  his  fingers.  But  at  some  later  date,  usually  the  next  day 
at  latest,  a  skiagraphic  examination  should  be  made,  and  the  surgeon 
should  study  the  plate  before  dressing  the  fracture  again.  When  routine 
use  of  the  X-rays  is  made  in  this  way,  the  surgeon  will  find  them  a  posi- 
tive aid  in  making  a  diagnosis  in  other  cases,  even  those  where  no  skia- 
graphic examination  can  be  made;  he  will  learn  what  to  look  for,  and 
knowing  what  to  look  for  he  usually  will  find  it.  In  services  where  no 
X-ray  apparatus  is  provided,  the  surgeon  who  has  no  experience  with 
skiagraphic  diagnosis  elsewhere  will  let  many  an  elbow  injury  go  un- 
diagnosticated  or  diagnosticated  inaccurately;  while  he  who  is  thoroughly 
familiar  with  the  valuable  information  derived  from  a  skiagraph  of 
similar  cases  will  be  able  to  assert  with  certainty  that  the  injury  present 
conforms  to  a  certain  type. 

Mere  radioscopic  inspection  of  an  injured  elbow  should  never  suffice; 
the  radiographic  plate  is  a  sine  qua  non  for  intelligent  interpretation. 

In  making  the  radiograph  the  film  side  of  the  plate  is  placed  next  the 
patient's  limb,  and  the  picture  etched  on  the  plate  is  the  shadow  of  those 


60  FRACTURES  OF  TFIE  ELBOIV 

parts  impervious  to  the  X-rays.  In  looking  at  the  developed  plate,  if 
it  is  held  with  the  film  side  toward  the  observer,  he  is  in  the  position 
occupied  by  the  Crookes  tube  when  the  exposure  was  made,  and  there- 
fore is  looking  at  the  shadow  of  the  elbow  bones  from  the  side  of  exposure. 
In  making  a  photographic  print  of  an  X-ray  plate  it  is  customar\',  for 
the  sake  of  getting  better  definition,  to  place  the  film  side  in  contact 
with  the  photographic  paper,  so  that  the  print  of  an  X-ray  plate  is  the 
reverse  of  the  plate  as  ordinaril\-  viewed.  Thus,  in  making  a  skiagraph 
of  the  elbow  in  antero-posterior  view,  the  posterior  surface  of  the  elbow 
is  placed  in  contact  with  the  film  of  the  X-ray  plate,  and  the  skiagraph 
when  developed  will  represent  the  elbow  viewed  from  the  front,  if  the 
plate  is  held  up  against  the  light  with  the  film  side  toward  the  observer; 
if,  however,  the  plate  is  observed  with  the  film  side  away  from  the  observer 
the  elbow  will  appear  as  if  vieiucd  from  behind;  and  prints  made  from 
this  plate  will  represent  the  elbow  viewed  from  behind.  This  is  an 
important  point  to  remember,  as  confusion  easily  arises  if  the  observer 
forgets  his  own  point  of  view.  In  making  a  lateral  view  of  the  elbow, 
the  bone  in  contact  with  the  film  is  more  clearly  defined  than  the  other. 
Usually  the  inner  side  of  the  elbow  is  in  contact  with  the  film,  so  that 
the  ulna  and  internal  cond)  le  are  more  clearly  defined  than  the  external 
condyle  and  the  radius.  But  reversing  a  lateral  view,  as  is  done  in 
printing,  makes  a  much  less  noticeable  change  than  does  reversing  an 
antero-posterior  view.  Yet  it  is  well  to  remember  that  ordinary  skia- 
graphic  prints  of  lateral  views  of  the  elbow  appear  as  if  viewed  from  the 
inner  side  of  the  elbow.  In  the  case  of  the  skiagraphs  reproduced  in 
this  work  I  have  taken  pains  to  indicate  the  observer's  point  of  view 
whenever  contusion  seemed  likely  to  arise. 


SUPRACONDYLAR  FRACTURES. 

There  are  21  recent  cases  of  this  t\  pe  m  ni\'  series  (Cases  i  to  21). 
It  is  the  most  frequent  t\  pe,  constituting  37.5  per  cent,  of  the  cases. 
The  age  of  the  patients  varied  from  fourteen  months  (Case  7)  to  eleven 
years.  No  cases  were  observed  in  adults.  During  the  same  period 
of  time  (1903  10  1909),  9  cases  of  dislocation  of  the  elbow  were  treated, 
4  of  which  were  in  adults  (aged  thirty-seven,  forty-five,  forty-eight, 
and  forty-nine  years),  and  5  in  children  (aged  nine,  twelve,  twelve, 
fourteen,  and  fourteen  years);  thus,  all  but  one  of  the  children  with  dis- 
location of  the  elbow  were  older  than  the  oldest  patient  with  supra- 
condylar fracture.  As  has  already  been  pointed  out  (page  26),  the  bones 
in  adults  are  stronger  than  the  ligaments,  so  that  falls  causing  sudden 
hyperextension  of  the  elbow  as  a  part  of  the  injury  are  more  likely  to 
cause  dislocation  than  fracture.     Most  fractures  of  the  lower  end  of  the 


SUPRACONnri.AR  FR  ICTURES  f.l 

humerus  in  adults  are  from  direct  violence,  the  joint  being  crushed, 
caught  in  a  revolving  shaft,  etc.;  they  are  frequently  compound,  and 
operative  treatment  (amputation,  removal  of  splinters,  fixation)  is  often 
indicated.  If  not  complicated  by  injury  to  the  soft  parts,  a  dislocation 
often   co-e.xists. 

Mechanism. — As  the  patients  usually  are  children,  they  frequently 
are  unable  to  tell  how  the  injury  was  received;  moreover,  in  a  large 
dispensary  service  the  mechanism  of  the  injury,  even  if  known,  some- 
times is  not  recorded.  I  find  that  among  these  21  cases  of  supra- 
condylar fracture  there  is  no  note  how  the  injury  was  received,  or  it  is 
recorded  that  the  mechanism  was  "uncertain,"  in  5  cases;  leaving  16 
cases  in  which  some  statement  as  to  the  mechanism  is  made. 

In  6  it  is  recorded  simply  as  "from  a  fall"  (presumahh'  on  the  out- 
stretched hand,  which  is  the  natural  way  for  a  child  to  fall).  In  3  it  is 
recorded  specifically  as  "from  a  fall  on  the  outstretched  hand."  In  i 
(Case  11)  the  cause  was  a  fall  on  the  flexor  surface  of  the  forearm,  causing 
hyperextension  of  the  elbow.  In  4  the  cause  was  a  fall  on  the  extensor 
surface  of  the  forearm,  the  elbow  being  flexed  at  about  a  right  angle. 
In  I  (Case  8)  the  cause  was  a  fall  on  the  outer  side  of  the  elbow  which 
was  fully  extended.  This  caused  a  comminuted  fracture.  In  i  (Case  q) 
the  elbow  was  caught  between  the  uprights  of  a  balustrade. 

It  will  be  noted  that  in  the  first  three  groups,  comprising  10  cases 
(6  +  3+1),  the  mechanism  consisted  in  a  thrusting  force  on  the  elbow 
in  the  long  axis  of  the  forearm,  thus  causing  violent  hyperextension  of 
the  elbow.  That  this  (thrust  +  hyperextension)  is  the  most  frequent 
mechanism  has  been  stated  at  page  51.  It  is  surprising  that  in  no  less 
than  4  cases  the  fracture  should  have  been  caused  by  falls  on  the  extensor 
surface  of  the  flexed  forearm.  Expermientally  such  an  injury  has  been 
found  more  apt  to  cause  a  transverse  diacondylar  fracture  or  even  an 
epiphyseal  separation;  but  e\en  thus  it  is  worthy  of  note  that  in  two 
of  these  four  cases  in  which  the  injury  was  caused  by  a  fall  on  the  flexed 
forearm  the  hne  of  fracture  was  low,  conforming  very  closely  to  the 
diacondylar  type  (Cases  12  and  18). 

I  have  tried  to  produce  a  supracondylar  fracture  of  the  humerus  in 
the  (adult)  cadaver  by  indirect  violence: 

I.  By  repeated  blows  with  a  heavy  mallet  on  the  overextended  palm, 
with  the  elbow  flexed  at  a  right  angle,  and  the  cond\les  of  the  humerus 
projecting  be}'ond  the  edge  of  the  table.  No  fracture  could  be  produced. 
I  2.  By  blows  on  the  overextended  palm  with  the  elbow  fully  extended. 
No  fracture  could  be  produced. 

3.  By  blows  on  the  sawed  end  of  the  humerus,  the  limb  resting  on 
the  overextended  palm  and  the  elbow  being  fully  extended.  No  fracture 
could  be  produced. 


62 


FRACTURES  OF  TFIR  ELBOW 


The  typical  fracture  shown  in  Fig.  57  could  only  be  produced  by  a 
blow  on  the  extensor  surface  of  the  humerus  above  the  condyles,  the 
elbow  being  flexed  at  a  right  angle,  and  the  limb  resting  on  the  over- 
extended palm.  This  really  was  by  direct  violence.  I  attribute  the 
failure  to  cause  a  fracture  by  indirect  violence  partly  to  the  inefficiency 
of  the  force  employed  (the  bones  were  those  of  an  adult,  not  a  child), 
and  largely  to  the  absence  of  the  hyperextension  of  the  elbow  which 
tears  off  the  condyles.  In  children's  cadavers  this  fracture  is  easily 
produced  by  simple  hyperextension.  Kocher  records  the  case  of  a 
patient   (adult   man)   who   had    a    supracond\lar   fracture   produced    by 


Fig.  57. — Experimental  supracondylar  fracture,  at  right  angles. 

simple  hyperextension  of  the  elbow,  another  man  having  placed  the 
patient's  elbow  on  his  own  shoulder  and  then  attempting  to  raise  the 
patient  from  the  ground  bv  pulling  downward  on  his  forearm. 

Symptoms. — Apart  from  s\mptoms  common  to  all  fractures  (pain, 
disability,  tenderness,  swelling,  etc.),  which  need  not  be  further  dis- 
cussed, the  most  important  signs  to  look  for  are  deformity,  crepitus, 
and  point  of  false  motion. 

The  deformity  somewhat  resembles  that  of  posterior  dislocation  of 
the  elbow.  The  differential  diagnosis  of  these  injuries  has  been  so  often 
insisted  upon,  that  it  is  useless  to  dilate  upon  it  here;  but  I  think  Chutro 
does  well  to  quote  Dupuvtren's  advice  "Si  un  medecin  disait  qu'il  y  a 
luxation  et  qu'un  autre  affirme  qu'il  y  a  fracture,  on  ne  doit  pas  balancer 


SUPRACONDYLAR  FRACTURES  63 

de  suivre  I'avis  c!e  ce  dernier,  parceque,  dans  cet  opinion  il  ne  laisse 
courir  aucun  chance  de  deformation,  d'impotence,  et  des  maladies 
consecutives."  Not  only  is  it  true  that  the  prognosis  will  be  better  in 
the  case  of  a  dislocation  treated  as  a  fracture  than  in  that  of  a  fracture 
treated  as  a  dislocation,  but  it  is  a  much  more  usual  thing  for  a  fracture 
to  be  considered  a  dislocation  than  the  contrary.  And  it  is  particularly 
worth  noting  that  supracondylar  fractures  often  are  accompanied  by 
very  slight  (sometimes  by  no)  deformity,  and  that  owing  to  swelling  it 
may  be  impossible  to  recognize  deformity  even  when  it  exists.  Fre- 
quently the  only  appreciable  bony  deformity  will  be  a  projection  of  the 
upper  fragment  in  the  bend  of  the  elbow;  if  this  projection  is  sharp  and 
jagged,  the  injury  is  nearly  certain  to  be  a  fracture  above  the  condyles. 
In  diacondylar  fractures  the  upper  fragment  does  not  protrude  so  much, 
and  is  more  rounded  in  contour.  So  that  two  things  especially  are  to  be 
remembered  in  regard  to  the  deformity  of  supracondylar  fractures:  (i) 
In  case  of  doubt  as  to  the  diagnosis  of  fracture  or  dislocation,  incline 
to  the  diagnosis  of  fracture;  (2)  many  injuries  to  the  elbow  without 
appreciable  deformity  will  be  found  by  their  subsequent  course  to  have 
been  cases  of  fracture.  In  either  case  the  injury  should  be  treated  as 
if  it  really  was  a  fracture  until  the  contrary  is  proved. 

Crepitus  is  present  with  very  few  exceptions;  but  in  impacted  frac- 
tures, which  are  not  very  rare,  it  will  not  be  obtained  until  the  fragments 
have  been  released  in  the  effort  of  reduction  (Cases  18,  19,  20).  The 
methods  of  eliciting  crepitus  in  supracondylar  fracture  already  have  been 
alluded  to  (page  57):  they  consist  in  (i)  movements  of  flexion  and  exten- 
sion; (2)  back-and-forth  movements  of  the  lower  fragment  on  the 
upper,  secured  by  manipulation  of  the  forearm;  and  (3)  in  rotatory 
movements  of  the  lower  on  the  upper  fragment.  It  is  not  necessary 
to  secure  crepitus  more  than  once  to  assure  one's  self  of  its  presence;  the 
infliction  of  additional  pain  on  the  patient  merel\'  for  the  edification 
of  by-standers  is  to  be  condemned. 

A  point  of  false  motion  can  seldom  be  detected  unless  there  is  crepitus. 
It  is  best  demonstrated  by  adducting  and  abducting  the  forearm  with 
the  elbow  in  full  extension.  As  previously  stated  (page  58),  this  sign 
may  be  present  in  fracture  of  either  condyle,  and  it  is  only  bv  ascertain- 
ing that  both  condyles  move  with  the  forearm  that  the  surgeon  can 
conclude  on  the  presence  of  supracondylar  fracture. 

Pathological  Anatomy. — The  direction  of  the  fracture  usualh'  is  from 
behind,  downward  and  forward.  As  a  consequence  there  is  persistent 
tendency  to  backward  and  upward  displacement  of  the  lower  fragment, 
which  becomes  tilted,  the  condyles  being  posterior,  and  the  fractured 
surface  more  or  less  anterior.  The  displacement  of  the  lower  fragment 
is  due  (i)  to  the  fracturing  force;    (2)  to  the  action  of  the  triceps,  which 


64 


FRACTURES  Of  THE  ELBOIV 


draws  the  olecranon  backward  and  upward;  (3)  to  the  brachialis  anticus 
and  biceps,  which  draw  the  lower  fragment  upward;  and  (4)  to  the  action 
of  the  muscles  joining  the  lower  fragment  with  the  forearm  and  hand, 
all  of  which  tend  to  rotate  it  forward  around  a  transverse  axis,  and  to 
keep  it  flexed  on  the  bones  of  the  toreariri.  These  muscles  (those 
arising  respectively  from  the  epitrochlea  and  epicondyle)  are  the  only 
muscles  attached  to  the  loiuer  fragment.  1  hus,  it  will  be  observed,  the 
lower  fragment  remains  flexed  in  relation  to  the  forearm;  and  when  the 
forearm  is  fully  extended  the  lower  fragment  is  tilted  still  more  trans- 
versely by  the  tension  on  the  muscles  attached  to  the  epitrochlea  and 


Fig.  5S. — Experimental  supracondylar  fracture,  in  hyperflexion. 


epicondvle.  Only  when  the  forearm  is  acutelv  flexed  on  this  lower 
fragment  (which  can  be  controlled  onh'  through  the  medium  of  the  fore- 
arm) will  these  muscles  cease  to  be  tense  and  to  flex  the  lower  fragment 
on  the  forearm  (Fig.   58). 

The  periosteum  on  the  posterior  surface  of  the  humerus  is  not  always 
completely  torn  through,  even  in  cases  of  supracond^  lar  fracture  with 
great  displacement.  Sometimes  it  is  stripped  up  from  the  posterior 
surface  of  the  humerus,  but  remains  as  a  bridge  passing  from  the  dis- 
placed lower  fragment  up  to  the  shaft  of  the  humerus  several  inches 
above  the  line  of  fracture.     Lusk  has  recenth'  called   attention   to  the 


SUPRA COND rU R  JR.I C TURES 


65 


difficLiltv  which  this  periosteal  bridge  offers  to  reduction.  He  has  not 
noted,  however,  the  fact  that  unless  reduction  is  accomplished  and  the 
periosteum  re-applied  as  nearly  as  may  be  to  the  posterior  surface  of  the 
shaft  of  the  humerus,  the  blood  which  is  effused  between  it  and  the  shaft 
will  become  organized,  and  by  proliferation  of  the  periosteum  marked 
thickening  of  the  shaft  of  the  humerus  will  occur,  with  the  result  that 
complete  reduction  of  the  fracture  very  quickly  may  become  impossible. 
Fig.  59,  a  skiagraph  made  ten  days  after  a  supracondylar  fracture  was 
received,  shows  a  barely  perceptible  shadow  passing  from  the  displaced 
lower  fragment  up  several  inches  before  it   joins  the  posterior  surface 


Fig.  59. — Skiagraph   of  supracondylar  fracture,  showing  stripping  up  of   periosteum, 

after  ten  days. 


of  the  shaft  of  the  humerus — this  shadow  being  cast  by  the  stripped-up 
periosteum,  as  is  clearly  demonstrated  in  Fig.  60,  from  a  skiagraph 
made  two  weeks  later.  In  Fig.  60  the  shadows  cast  by  the  adhesive 
strips  employed  to  retain  the  dressing  may  also  be  seen;  but  the  newly 
formed  subperiosteal  bone  casts  a  very  distinct  shadow,  and  binds  the 
unreduced  lower  fragment  in  its  position  of  backward  displacement.  When 
this  girl  (aged  eight  years)  first  came  under  my  care  (November  3,  1905), 
over  five  weeks  after  the  injurv,  I  found  her  with  an  elbow  possessing 
only  15  to  20  degrees  of  motion,  being  nearl\-  ank\losed  at  a  right  angle. 
Examination  of  the  skiagraphs  previously  made  (Fig.  59,  made  Septem- 
ber 8,  1905,  and  Fig.  60,  made  September  22,  1905)  showed  the  existence 


66 


FRACTURES  OF  THE  E LEO  IV 


of  an  unreduced  supracondylar  fracture,  the  arm  having  been  dressed 
at  a  right  angle  on  an  anterior  angular  splint.  In  attempts  at  flexion 
the  coronoid  process  of  the  ulna  butted  against  the  lower  extremity 
of  the  upper  fragment  in  the  bend  of  the  elbow,  and  extension  also 
was  impossible,  probably  from  fibrous  adhesions.  The  child  was 
therefore  etherized  (November  3,  1905),  and  forcible  movements  of 
flexion  and  extension  were  made  (arthrolysis);  the  gunstock  deformity 
(varus)  evident  when  the  forearm  was  fully  extended  under  the  anaes- 
thetic was  corrected,  the  lower  fragment  being  forcibly  refractured  from 


Fig.  60. — Skiagraph  of  supraconthlar  fracture,  showing  stripping  up  of  periosteum, 

after  three  weeks. 


the  upper.  The  corrected  position  is  shown  in  Fig.  61,  from  a  skiagraph 
made  some  days  later,  the  elbow  having  been  dressed  in  hyperflexion. 
This  patient  was  kept  under  observation  until  September,  1907,  at  which 
date  she  had  motion  in  the  elbow  from  60  to  no  degrees,  the  motion  so 
far  being  perfectly  free,  but  being  checked  abruptly  m  both  flexion  and 
extension,  as  if  by  bony  contact.  Operation  was  urged,  but  the  parents 
thought  the  arm  sufliciently  useful  as  it  was,  since  the  child  could  now 
get  her  hand  to  her  mouth.  This  case  goes  to  show  both  the  evil  result 
of  neglect  to  obtain  accurate  reduction  of  the  fracture,  and  the  futilit\  of 


SUPRACOND]  LJIi  Hi.lCTUIiES 


67 


arthrolvsis   as   a   remedial  measure;    the   increased    range  of  motion    so 
obtained  was  only  a  little  over  30  degrees. 

Chutro  (loc.  cit.,  p.  232)  describes  a  fracture  closely  resembling  this, 
but  classifies  it  apart  from  other  supracondylar  fractures  as  a  "rare 
variety;"  but  it  seems  to  me  he  has  wrongly  interpreted  his  skiagraphs 
as  showing  an  upward  splitting  of  the  inner  part  of  the  humeral  shaft. 
It  is  true  that  tlu-  skiagraphs  con\e\  this  impression,  and  I  was  tor  a 
long  time  misled  by  the  skiagraph  of  mv  own  patient  (Fig.  60)  into 
thinking  that  in  her  case  the  shaft  of  the  humerus  had  been  split  upward; 


Fig.  61. — Skiagraph  of  same  case,  elbow  in  livpeitlcxion,  after  arthrolysis. 


but  when  I  had  observed  a  number  of  other  similar  skiagraphs,  made 
at  varying  periods  after  the  fractures,  and  showing  the  progressive 
growth  of  the  subperiosteal  bone,  I  finalh  detected  in  Fig.  59  (on  re- 
examination) a  faint  shadf)w  undoubtedly  cast  by  the  periosteum  itself; 
and  this  proved  to  m\'  mind  that  the  appearances  in  Fig.  60  were  decep- 
tive, and  due  soleh'  to  new  bony  outgrowth,  and  not  to  a  splitting  of  the 
humeral  shaft.  This  stripping  of  periosteum  I  have  noticed  in  a  number 
of  my  recent  cases,  in  addition  to  that  of  the  ancient  fracture  detailed 
above  (Case  i.  Fig.  71;  Case  11,  Fig.  84;  Case  18,  Fig.  94;  Case  47, 
Fig.    136;     Case  55,   Fig.    149).      It  is  a  feature  of  fractures  about  the 


68  l-'RACrURES  OF  THE  ELBOII' 

elbow  whicli  lias  not  been  sufficiently  recognized.  Even  in  anterior 
displacement  of  the  lower  fragment  the  periosteum  may  be  stripped 
up  from  the  anterior  surface  of  the  humerus,  as  shown  in  Fig.  62 
(diacondylar  fracture). 

Forward  displacement  of  the  lower  fragment  (Kocher's  fracture  by 
flexion)  was  not  encountered  in  the  present  series  of  supracondylar 
fractures,  though  it  was  seen  in  one  case  of  diacondylar  fracture  (Case 
24).  As  already  noted,  it  is  generally  considered  very  rare.  Mouchet 
has  seen  it  only  once  among  78  supracondylar  fractures.  Yet  Hilgen- 
reiner  records  8  fractures  by  flexion  among  21  supracondylar  fractures; 
but  only  2  of  these  cases  were  in  children.  It  should  be  borne  in  mind 
that  forward  displacement  may  not  be  the  primary  deformity,  but  that 
it  may  be  produced  by  manipulation  b\  b\-standers  or  the  surgeon 
himself,  before  an  X-ray  examination  is  made. 

In  any  case,  however,  it  is  rare  for  the  lower  fragment  to  be  displaced 
directly  exxhtr  forward  or  backward;  a  lateral  deviation  is  not  infrequent, 
and  the  fragment  may  also  be  slightly  rotated  on  an  antero-posterior 
axis,  so  that  the  external  cond\le  is  displaced  downward  and  the  internal 
upward,  or  even  in  the  opposite  direction.  This  must  be  remembered 
in  reducing  the  fracture. 

Treatment. — In  supracondv  lar  fractures,  as  in  fractures  in  all  other 
parts  of  the  body,  the  indications  for  treatment  are  to  reduce  the  frag- 
ments and  maintain  them  in  accurate  apposition  until  consolidation 
takes  place. 

Reduction  is  accomplished  with  due  regard  to  the  displacement  present 
and  to  the  factors  which  produce  it.  The  fragments  are  often  more 
or  less  impacted,  and  much  more  force  must  be  used  to  unlock  them 
and  secure  reduction  than  is  commonly  believed.  By  hyperextension, 
traction  in  the  long  axis  of  the  limb,  and  then  by  forced  flexion  into  the 
position  termed  in  this  work  hvperflexion,  reduction  is  easily  obtained 
in  recent  cases,  and  the  good  position  secured  is  maintained  b\'  the  aid 
of  nature.  Hyperextension  of  the  elbow  should  be  carried  just  suffi- 
ciently be}'ond  a  straight  line  to  free  the  lower  fragment  from  the  upper, 
without  causing  the  upper  fragment  to  protrude  so  far  in  the  bend  of 
the  elbow  as  to  endanger  the  soft  parts.  This  act  of  hyperextension 
momentarih-  increases  the  deformity  by  rotating  the  lower  fragment 
on  its  transverse  axis  (page  64);  this  separates  the  fractured  surface 
of  the  lower  fragment  from  the  shaft  of  the  humerus,  and  b\'  using  the 
triceps  and  the  bridge  of  periosteum  (when  it  exists)  as  a  hinge,  permits 
the  subsequent  manipulations  to  be  successfully  carried  out.  Having 
thus  relieved  the  impaction  and  freed  the  fragments,  the  surgeon  presses 
backward  on  the  shaft  of  the  humerus  (counter-extension)  while  he  makes 
traction   (extension)  on   the  forearm,  firmly  and   unhesitatingly  bringing 


SUPR/ICONDTLAR  FRACTURES 


m 


Figs.  62  and  63. — Skiagraphs  of  iliacondylar  fracture  "by  flexion,"  showing  periosteum 
stripped  up  from  anterior  surface  of  humerus. 


70  FRACTURES  OF  THE  ELBOIV 

it  up  into  the  jiosition  of  li\perflexion,  and  taking  care  to  maintain  the 
ground  previously  gained  by  keeping  up  traction  on  the  forearm  until 
the  angle  between  the  forearm  and  arm  has  been  decreased  to  at  least  30 
degrees.  In  bringing  the  forearm  up  toward  the  arm,  the  surgeon  must 
be  very  particular  not  to  rotate  the  lower  fragment  on  the  axis  of  the 
shaft  of  the  humerus;  if  the  lower  fragment  is  rotated  inward,  b\-  undue 
adduction  of  the  forearm,  cubitus  varus  will  result;  if  it  is  rotated  out- 
ward by  excessive  abduction  of  the  forearm,  cubitus  valgus  W\\\  result. 
In  either  case  the  relation  of  the  articular  surface  of  the  humerus  to  the 
long  axis  of  this  bone  will  be  changed,  and,  as  pointed  out  at  pages  28 
and  29,  this  is  the  prime  cause  of  distortions  ot  the  carrying  angle.  If 
the  forearm  is  flexed  in  such  a  manner  that  its  axis  corresponds  with  that 
of  the  humerus,  viewed  in  the  sagittal  plane  (the  humerus  itself  being 
rotated  neither  outward  nor  inward),  the  normal  obliquity  of  the  artic- 
ular end  of  the  humerus  must  be  preserved  (Figs.  16  and  17).  In  any 
case  of  uncertaint\'  it  is  best  to  err  on  the  side  of  too  great  abduction  of 
the  forearm,  as  cubitus  valgus  is  a  much  less  disabling  and  less  con- 
spicuous deformity  than  is  cubitus  varus. 

Retention. — Having  reduced  the  fracture,  the  next  problem  is  to  retain 
the  fragments  in  proper  position.  As  has  already  been  pointed  out 
(page  26),  the  position  of  hyperflexion  is  the  position  of  greatest  stability. 
It  is  best  adapted  for  retaining  the  fragments  of  a  supracondylar  fracture 
in  place  for  many  reasons:  The  lower  fragment  is  kept  flexed  on  the 
forearm  b\'  the  muscles  attached  to  the  epicond)  le  and  epitrochlea;  there- 
fore, to  prevent  the  original  deformit\'  from  recurring,  the  forearm  must 
be  kept  flexed  at  any  rate  to  a  right  angle.  But  when  the  elbow  is  at 
a  right  angle,  the  triceps  acts  in  a  plane  posterior  to  the  axis  of  the  humerus, 
so  that  it  constantly  tends  to  draw  the  olecranon,  and  with  it  the  lower 
fragment  of  the  humerus,  backward  (Fig.  64,  a);  when,  however,  the 
elbow  is  hyperflexed,  the  point  of  insertion  of  the  triceps  is  carried  anterior 
to  the  longitudinal  axis  of  the  humerus,  so  that  the  action  of  this  muscle 
on  the  lower  fragment  is  no  longer  in  a  plane  posterior  to  that  of  the 
humerus,  but  tends  to  crowd  the  lower  fragment  directly  into  the  place 
where  it  should  be  (Fig.  64,  b).  The  triceps  becomes  very  tense  in  the 
position  of  hyperflexion,  and  it  passes  down  behind  the  condyles  and 
around  under  them  to  its  insertion  on  the  subcutaneous  portion  of  the 
olecranon  precisely  like  a  sling;  and  so  long  as  the  position  of  hyper- 
flexion is  maintained,  with  an  intact  triceps,  posterior  displacement  of 
the  lower  fiagment  is  impossible,  while  the  direction  of  the  fractured 
surface  and  the  contact  of  the  soft  parts  efi^ectually  guards  against  for- 
ward displacement.  When  the  elbow  is  dressed  at  a  right  angle  its 
position  must  be  maintained  by  a  splint  of  wood  or  of  plaster.  In  this 
country  a  wooden   splint  is  generally   used,  either  an  internal  angular 


SUPRACONDl'LAR  JRJCTURES 


71 


(Physick's  splint)  or  an  anterior  angular  (Hartshorne's).  With  such  a 
dressing  it  is  exceedingly  difficult  to  overcome  the  action  of  the  triceps, 
which  constantly  tends  to  backward  displacement  of  the  lower  fragment. 
Even  bandaging  the  upper  arm  first  to  the  vertical  portion  of  the  splint, 
and  then  keeping  up  traction  on  the  forearm,  as  this  part  is  bandaged 
to  the  horizontal  portion  of  the  splmt,  is  rarely  efficient  in  overcoming 
this  backward  displacement  ot  the  lower  fragment.  Coenen  uses  plaster 
of  Paris,  and  while  it  is  setting  one  assistant  drags  backward  on  the 
humerus  through  means  of  a  slmg,  while  another  makes  traction  on  the 
forearm,  the  patient   being   anaesthetized;   he  is  quite  satisfied  with    his 


Fig.  64. — Diagram  to  show  action  of  triceps  with  elbow  in  extension  (a), 
and  in  hyperffexion  {b). 


results,  though  his  experience  appears  to  be  confined  to  8  cases,  2 
patients  recovering  with  cubitus  varus.  The  experience  detailed  and 
the  skiagraphs  reproduced  in  connection  with  the  fifth  case  of  my  series 
(Figs.  75,  76,  and  77)  make  clear  the  difficulty  of  retention  at  a  right 
angle.  Another  objection  to  the  maintenance  of  the  elbow  at  a  right 
angle  on  a  splint  is  that  rotation  of  the  lower  fragment  on  the  upper, 
around  a  longitudinal  axis,  is  not  prevented ;  when  the  arm  is  first 
dressed  the  forearm  is  in  the  sagittal  plane,  but  when  it  is  put  in  a  sling 
and  carried  against  the  body,  it  has  rotated  through  an  angle  of  fully 
60  degrees,  and  when  in  the  sling  lies  more  nearly  in  the  frontal  than  in 


72  FRACTURES  OF  THE  EEBOIf 

the  sagittal  plane.  Now,  in  this  rotation  it  is  almost  unavoidahle  for  the 
relation  of  the  fragments  to  be  altered,  as  the  shaft  of  the  humerus  is 
cylindrical,  and  any  splint  gets  only  a  weak  grip  on  it;  so  that  it  is  too 
much  to  expect  that  the  splint  will  rotate  the  upper  fragment  as  much 
as  it  does  the  lower,  which  is  firmly  attached  to  the  forearm  b\'  the  lateral 
ligaments  of  the  elbow.  It  was  to  avoid  this  very  rotation  that  Dau- 
vergne,  in  1873,  adopted  the  position  of  hvperflexion  for  the  treatment 
of  these  injuries. 

The  fear  ot  gunstock  deformity  {cubitus  varus  or  valgus)  led  Allis, 
and  after  him  Roberts,  Lane,  and  others,  to  employ  the  position  of 
complete  extension,  previously  used  by  Pezerat  (1832),  Berthomier 
(1875),  and  advocated  b\-  Liston,  Bardenheuer,  Heusner,  and  others. 
While  it  is  true  that  the  carrying  angle  is  evident  only  in  full  extension, 
it  is  not  true,  I  think,  that  it  cannot  be  preserved  without  resort  to  a 
position  extremely  irksome  to  the  patient,  and  one  which  neither  over- 
comes the  posterior  displacement  of  the  lower  fragment  nor  prevents 
its  axial  rotation  on  the  upper.  Moreover,  should  ankylosis  occur 
(which  I  believe  is  vastly  more  probable  in  the  extended  than  in  the 
hyperflexed  position),  the  arm  will  be  in  a  position  of  all  others  the  least 
to  be  desired. 

It  is  most  important  to  restore  the  articulating  surface  of  the  humerus 
to  its  normal  anterior  position  (Fig.  i);  even  more  important,  I  believe, 
than  the  preservation  of  the  carrying  angle;  and  inasmuch  as  hyper- 
flexion  of  the  elbow  accomplishes  the  former  better  than  any  other 
position,  and  when  properh'  employed  insures  the  preservation  of  the 
carrying  angle  quite  as  well  as  does  an\-  other  position,  I  earnestly  advo- 
cate it  as  the  best  position  for  treatment  of  supracond\lar  fractures. 

The  dressing  used  to  maintain  the  position  of  hyperflexion  is  described 
at  page  88. 

Results. — Of  these  21  cases  of  supracond\lar  fracture,  4  (Cases  i, 
6,  14,  16)  cannot  be  traced;  the  onl\-  one  of  the  four  in  which  a  perfect 
result  was  not  anticipated  was  Case  14;  this  patient  (aged  five  years) 
fell  and  aeain  injured  her  elbow  ten  days  after  it  was  removed  from  the 
slinp,  and  aeain  a  week  later  had  her  elbow  injured  for  the  third  time 
in  a  trolley-car  collision;  when  last  seen,  six  weeks  after  her  third  injury, 
she  had  a  range  of  motion  from  75  degrees  to  no  degrees,  with  no 
pain.  This  range  of  motion  might  be  expected  to  improve  considerably. 
Repeated  efforts  to  learn  her  further  histor\-  have  been  unavailing. 

In  one  of  the  patients  traced  (Case  2),  who  was  treated  on  an  internal 
angular  splint,  slight  loss  of  the  carr\ing  angle  was  noted  over  three 
years  after  the  fracture  for  which  I  treated  the  patient;  but  as  one  year 
after  she  was  under  my  care  (two  years  before  my  final  examination) 
she  again  fractured  the  same  elbow,  and  was  treated  hv  another  physician, 


DLICONDYLAR  FRACTURES  73 

I  am  not  entirely  sure  that  the  loss  ot  the  carr\  ing  angle  is  to  he  charged 
up  to  mv  account. 

In  the  i6  other  patients  with  supracoiuh  lar  fracture  the  result  must 
be  classed  as  perfect — by  which  I  understand  no  limitation  of  motion 
in  flexion  or  extension,  and  preservation  of  the  carrying  angle.  All 
these  patients  were  treated  in  hyperflexion. 

If,  then,  in  i6  out  of  21  cases  (80  per  cent.)  the  results  are  known  to  be 
perfect;  if  in  three  more  the  result  is  probably  perfect  (19  out  of  21,  or 
90  per  cent.);  and  if  in  the  two  cases  where  the  result  is  not  perfect 
(Cases  2  and  14)  there  exist  extenuating  circumstances  in  the  nature 
of  subsequent  injuries,  I  think  it  may  be  asserted,  with  some  show  of 
truth,  that  a  gloomy  prognosis  in  cases  of  uncomplicated  supracondylar 
fractures  has  no  place  in  modern  surgery. 


TRANSVERSE  DIACONDYLAR  FRACTURES. 

There  are  8  recent  cases  of  this  t\pe  in  n-\\  series  (Cases  22  to  29). 
Most  surgeons  make  no  distinction  between  this  t\pe  and  supracondylar 
fractures,  though  many,  as  Stimson,  recognize  a  "low  supracond\lar 
fracture."  Kocher  records  only  one  case  among  those  published  in 
1896;  this  he  represents  m  an  illustration,  giving  the  line  of  fracture 
approximateh'  along  the  epiphyseal  line,  though  he  did  not  consider  it 
a  case  of  epiph}seal  separation.  As  his  illustration  was  made  from  the 
clmical  findings  alone,  before  the  X-rays  came  into  general  use,  it  is 
possible  that  it  does  not  accurately  represent  the  condition  present.  In 
my  own  cases  I  have  been  inclined  to  class  as  diacondylar  all  transverse 
fractures  distinctly  above  the  epiphyseal  line  which  nevertheless  invade 
the  joint.  As  will  be  seen  subsequently,  this  t\  pe  is  distinct  in  its 
causation,  as  well  as  in  its  clinical  course,  from  ordinary  supracond\lar 
fractures,  so  that  the  distinction  seems  to  me  well  worth  making. 

Mechanism. — It  is  generallv  the  case  that  transverse  diacond\lar  frac- 
tures are  produced  by  falls  on  the  extensor  surface  of  the  forearm  or 
the  elbow,  the  shock  knocking  ofi^  a  portion  of  the  lower  extremity  of 
the  humerus,  which  is  impacted  or  is  subsequenth^  displaced  b\-  muscular 
action.  Forward  displacement  of  the  lower  fragment  ma\'  be  attributed 
to  the  continuation  of  the  fracturing  force,  when  this  acts  forward 
(by  flexion);  backward  displacement  to  the  fracturing  force  aided  by 
the  contraction  of  the  triceps  muscle.  Unfortunately,  in  the  only  case 
in  this  series  in  which  there  was  simple  forward  displacement  of  the 
lower  fragment  (Case  24)  it  is  not  known  how  the  patient  was  injured, 
beyond  the  fact  that  the  injury  was  caused  by  falling  off  a  table;  but 
such  a  fall   is  not  so  apt  to   be  on   to  the  outstretched   hand    as  is  one 


74  FRACTURES  OF  THE  EEliOIV 

which  results  from  the  patient's  tripping  while  walking  or  running  on 
the  ground.  In  the  fracture  of  the  Posadas  t\pe  (Case  28),  the  patient 
fell  on  the  overextended  hand,  hut  to  determine  the  further  mechanism 
of  the  injury  seems  impossible;  probably  posterior  dislocation  occurred 
in  the  usual  way  by  h}perextension  of  the  elbow,  and  for  some  reason 
a  diacondylar  fracture  was  subsequently  produced.  When  this  rare 
injury  is  produced  by  a  fall  on  the  extensor  surface  of  the  partlv  flexed 
forearm,  Chutro  explains  the  mechanism  in  the  following  way:  The 
force  as  originally  applied  causes  a  diacondylar  fracture,  with  forward 
displacement  of  the  lower  fragment;  the  bones  of  the  forearm  accompany 
this  as  far  as  possible,  but  after  a  very  slight  excursion  in  this  anterior 
direction  the  point  of  the  olecranon  strikes  against  the  diaph\sis  of  the 
humerus  just  above  the  line  of  fracture,  the  result  being  that  the  ulna, 
and  with  it  the  radius,  is  arrested  sooner  than  the  lower  fragment  of  the 
humerus;  subsequently,  the  triceps  draws  the  ulna  upward  and  back- 
ward, completing  the  dislocation. 

Of  the  six  cases  in  my  series  of  the  ordinar}'  t\pe  of  diacondylar  frac- 
ture, the  mechanism  is  not  recorded  in  2;  in  only  i  case  did  the  frac- 
ture follow  a  fall  on  the  outstretched  hand;  it  followed  a  fall  on  the 
extensor  surface  of  the  flexed  forearm  in  2  cases,  and  a  fall  on  the  flexed 
elbow  in  i  case.  The  mechanism  in  the  latter  three  cases  conforms  to 
the  usual  type;  and  as  noted  at  page  61  the  fractures  produced  by  this 
mechanism  in  Cases  12  and  18  so  closely  resemble  diacond}lar  fractures 
that  their  inclusion  among  the  supracondylar  or  in  the  present  class  is 
a  matter  of  indifference. 

Symptoms. — The  s\mptoms  of  the  ordinary  diacondylar  fracture 
resemble  so  closely  those  of  the  supracondylar  that  there  is  little  to  be 
added  to  what  was  there  said.  Displacement  is  less  usual,  owing  to  the 
mechanism,  the  smaller  size  of  the  fragment,  and  to  its  being  partly,  at 
least,  intracapsular;  crepitus  is  rather  indistinct,  and  mobility  is  unusual. 
A  positive  diagnosis  from  supracond\lar  fracture  can  rarely  be  made 
without  the  use  of  the  X-rays;  and  in  many  cases  of  injury  to  the  elbow 
in  which  no  fracture  is  detected  clinicalh',  the  skiagraph,  in  either  antero- 
posterior or  lateral  view  (not  always  in  both),  will  reveal  the  presence  of 
a  diacondylar  fracture,  with  or  without  displacement.  If  there  is  dis- 
placement, a  lateral  view  will  be  more  apt  to  show  it;  if  there  is  no  dis- 
placement (Figs.  34  and  35),  the  fracture  is  best  seen  in  antero-posterior 
views.  The  symptoms  of  the  Posadas  t)'pe  are  discussed  sufficiently 
in  connection  with  Case  28  (page  129). 

Pathological  Anatomy. — The  line  of  fracture  almost  invariably  passes 
through  the  olecranon  fossa,  being  intracapsular  at  this  point.  The 
lower  fragment  often  is  more  or  less  crescent-shaped,  the  epicondyle 
and  epitrochlea  being  detached  with  the  fragment  and  forming  the  horns 


FR.lCrURRS  OF  THE  EXTERNAL  CONDTLE  75 

of  the  crescent,  while  the  portion  of  the  diaphysis  between  the  olecranon 
fossa  and  the  epiph\seal  hne  forms  the  body  of  the  crescent.  This 
fracture  has  in  some  unaccoiintahle  way  been  confused  by  many  writers 
with  epiphyseal  separation.  If  displacement  exists  it  is  more  apt  to  be 
lateral  (internal  or  external)  as  well  as  posterior  than  directly  posterior. 
In  3  of  my  cases  the  lower  fragment  was  displaced  chiefly  posteriorly, 
in  2  anteriorly  (Cases  24  and  28),  in  i  externally,  and  in  i  there  was  no 
displacement.     In  one  case  the  displacement  is  not  mentioned. 

Treatment. — This  is  practically  the  same  as  for  supracond}  lar  frac- 
tures, and  for  the  same  reasons.  Even  if  the  lower  fragment  be  dis- 
placed anteriorly,  the  position  of  hyperflexion  will  give  the  best  results. 

Results. — As  the  fracture  is  partly  intra-articular,  usually  involving 
the  thin  shell  of  bone  separating  the  coronoid  and  olecranon  fossae 
(Fig.  5),  the  results  are  not  so  good  as  in  supracond}  lar  fractures,  which 
are  entirely  extra-articular.  Of  the  six  cases  of  the  ordinary  type  of 
diacondylar  fracture  in  my  series,  the  result  is  classed  as  perfect  in  5; 
in  I  patient  (Case  23),  though  the  patient  has  no  deformity  and  full 
flexion,  yet  extension  is  limited  to  165  degrees,  the  result  therefore  being 
imperfect. 

The  result  in  the  case  of  diacond\lar  fracture  by  flexion  is  also  imper- 
fect, as  a  slight  (barely  perceptible)  cnhitus  varus  exists  (Fig.  106), 
though  flexion  and  extension  are  normal. 

The  patient  with  the  fracture  of  the  Posadas  type  (Case  28)  secured 
perfect  function,  with  full  flexion  and  full  extension;  but  in  my  anxiety 
to  prevent  varus  deformity  I  succeeded  in  giving  him  a  marked  cubitus 
■valgus  (Fig.  115);  but  as  in  every  other  case  of  this  type  to  which  I  have 
reference  the  result  was  nearly  complete  ankylosis  in  almost  full  exten- 
sion, it  has  seemed  fair  to  call  the  result  in  the  present  case  good. 

FRACTURES  OF  THE  EXTERNAL  CONDYLE. 

There  are  12  such  cases  in  my  series  (Cases  30  to  41).  The  age  of 
the  patients  varied  from  two  and  one-halt  to  twelve  years.  Some  surgeons 
consider  it  a  more  frequent  mjurv  than  the  supracondylar  variety. 

Mechanism. — This  is  not  recorded,  or  is  uncertain,  in  7  cases.  A  fall 
on  the  outstretched  hand  was  the  cause  in  2  cases  (Cases  32  and  35),  the 
head  of  the  radius  impinging  on  the  capitellum,  as  described  at  page  50, 
and  hyperextension  or  abduction  of  the  forearm  perhaps  aiding  in  pro- 
ducing the  fracture  (Figs.  50  and  51).  One  patient  (Case  36)  said  she 
fell  on  the  extensor  surface  of  the  flexed  forearm;  and,  as  noted  at  page 
54,  it  has  been  claimed  that  fractures  of  the  external  condyle  are  pro- 
duced in  this  way,  the  ulna  breaking  oft"  the  external  lip  of  the  trochlea 
when  forced  upward  by  contact  with  the  ground.     It  has  seemed  more 


7()  FRACTURES  OF  THE  FL/10(f 

likely,  however,  so  far  as  I  can  see,  that  the  injury  is  produced  rather 
by  a  fall  upon  the  acutely  flexed  elbow,  the  patient  landing  directly  upon 
the  external  condyle,  with  the  arm  close  against  the  body.  Fracture  by 
aJJuctioii  of  the  forearm  (Figs.  55  and  56),  as  described  at  page  55,  was 
the  cause  in  Cases  38  and  40;  these  patients  fell  to  the  ground,  crushing 
the  fully  extended  elbow  between  their  body  and  the  ground,  causing 
great  tension  on  the  external  lateral  ligament,  which  thus  produced  a 
sprain  fracture,  as  it  were,  of  the  external  condyle.  This  may  seem 
a  strange  explanation  of  the  mechanism  in  these  latter  cases,  as  adduc- 
tion of  the  forearm  is  quite  apt  to  result  in  subluxation  of  the  radius 
(pulled  elbow),  the  external  lateral  ligament  being  attached  not  to  the 
radius,  but  to  the  ulna,  through  the  medium  of  the  orbicular  ligament. 
But  as  fractures  ot  the  external  cond\le  are  quite  easily  produced  in  the 
cadavera  of  children,  experimentally,  by  simple  adduction  of  the  fore- 
arm, and  as  in  the  patients  who  sustain  the  injury  in  the  manner  described 
there  is  no  evidence  whatsoever  of  the  fracture  having  been  produced  by 
direct  violence  (the  only  other  mechanism  possible  under  the  circum- 
stances), it  seems  to  me  not  at  all  unreasonable  to  assign  the  injury  to 
ligamentous  action.  The  lateral  ligaments  are  much  stronger  than 
surgeons  generally  suppose. 

Symptoms. — Most  conspicuous  to  inspect  ion  is  localized  swelling  over 
the  external  cond\le,  and  loss  of  the  carrying  angle.  On  palpation 
the  epicondyle  usually  is  found  displaced  downward  and  forward,  and 
the  region  of  the  external  cond\le  is  much  more  sensitive  than  that 
of  the  internal.  The  fully  extended  forearm  can  be  readily  adducted 
and  abducted  at  the  elbow,  producing  alternate  cubitus  varus  and  valgus. 
Crepitus  can  be  elicited  sometimes  by  pushing  and  pulling  the  forearm 
back  and  forth,  thus  moving  the  external  condyle  on  the  shaft;  but  is 
more  often  to  be  detected  by  grasping  the  whole  external  condyle  between 
the  thumb  and  finger,  and  moving  it  fore  and  aft  while  the  shaft  of  the 
humerus  is  held  still  b\-  the  other  hand.  In  a  few  cases  where  the  condyle 
has  not  been  freeh'  detached,  1  have  succeeded  in  obtaining  crepitus 
only  by  gently  depressing  the  condyle  against  the  shaft,  when  a  slight 
tapping  sensation  was  perceived.  When  all  the  above  s}'mptoms  are 
present,  and  it  can  be  ascertained  that  the  internal  condyle  remains 
attached  to  the  shaft,  the  diagnosis  of  fracture  of  the  external  condyle 
is  certain  even  without  resort  to  a  skiagraph.  To  be  of  most  value  a 
skiagraph  should  show  an  antero-posterior  view,  although  even  an 
oblique  view  may  suffice  to  confirm  a  doubtful  diagnosis. 

Pathological  Anatomy. — The  line  of  fracture  invariably  enters  the 
joint;  mere  detachment  of  the  extra-articular  portion  of  the  external 
condyle  (termed  here  the  epicondyle)  I  have  never  observed.  The 
detached  fragment  includes  the  entire  capitellum  and  usuallv  the  outer 


FRACTURES  OF  THE  EXTERNAL  CONOrLE  77 

lip  of  the  trochlea.  The  only  muscles  attached  to  the  fragment  are 
those  arising  from  the  external  condyle;  the  brachio-radialis  and  the 
extensor  carpi  radialis  longior,  which  are  attached  also  to  the  supra- 
condylar ridge,  probably  limit  the  amount  of  displacement.  This 
displacement,  as  already  noted  under  symptomatology,  usually  is  down- 
ward and  forward,  due  slightly  to  muscular  action,  but  chiefly  to  the 
force  of  gravity,  by  which  the  forearm  falls  against  the  patient's  side, 
as  the  normal  support  which  maintains  the  carr\ing  angle  has  been 
destro\  ed. 

Treatment. — To  replace  the  fragment  in  its  proper  position  the  fore- 
arm must  he  abducted,  restoring  the  carrying  angle;  and  the  elbow  must 
be  flexed,  thus  forcing  the  external  condyle  backward.  By  bringing 
the  forearm  up  into  the  position  of  hyperflexion,  the  external  condyle 
is  then  held  firmly  in  its  normal  position  by  the  tense  triceps  behind  it, 
and  is  prevented  from  being  displaced  forward  by  contact  with  the  head 
of  the  radius  which  cannot  be  moved  forward  except  by  adduction  of  the 
forearm.  The  disability  which  follows  the  treatment  of  this  fracture 
on  an  anterior  or  an  internal  angular  splint,  arises  chief!}'  from  this  very 
fact,  that  adduction  of  the  forearm  (causing  anterior  displacement  of 
the  fragment)  is  not  prevented.  Moreover,  when  the  elbow  is  flexed  at 
a  right  angle,  downward  displacement  of  the  external  condyle  is  favored. 
Normally  the  radius  is  on  a  higher  plane  than  is  the  ulna  (Fig.  25); 
but  when  the  support  which  the  radius  receives  from  its  attachments 
to  the  humerus  is  destroyed,  as  is  the  case  in  fractures  of  the  external 
condyle,  the  head  of  the  radius,  and  along  with  it  the  condyle,  will  sag 
downward.  Moreover,  as  pointed  out  by  Allis,  the  use  of  an  anterior 
splint,  on  the  flexor  surface  of  the  forearm,  will  tend  to  force  the  radius 
down  to  the  same  level  as  the  ulna.  But  in  the  position  of  hyperflexion 
the  triceps  and  its  fibrous  expansion  become  so  tense  that  the  external 
condyle  is  held  firmly  in  its  normal  position  when  once  it  has  been 
replaced  there  (Fig.  58).  The  objections  to  the  position  of  full  extension 
are  the  downward  pull  of  the  muscles  attached  to  the  epicondyle,  which 
is  increased  with  the  degree  of  the  extension,  the  irksomeness  to  the 
patient,  and  the  difficulty  of  maintaining  the  carrying  angle  against  the 
force  of  gravit}'  which  constantU  tends  to  make  the  forearm  assume 
the  same  axis  as  the  arm.  ^'et  1  must  confess  that  I  ha\e  never  tried 
dressing  these  fractures  in  full  extension,  so  that  these  objections  on  my 
part  may  be  rejected  as  purely  theoretical;  but  the  results  from  hyper- 
flexion have  been  so  satisfactory,  both  to  myself  and  the  patients,  that 
I  have  not  thought  it  wise  to  experiment  with  a  position  which  does  not 
commend  itself  to  me  from  the  point  of  view  of  applied  anatomy. 

Results. — Eleven  of  my  cases  of  fracture  of  the  external  condyle  have 
been  traced.     In  10  the  result  is  classed  as  perfect;   in  i  (Case  ^^)  there 


78  tk.lCTURES  Of  THE  ELBUH 

is  very  slight  limitation  ot  extension,  and  scarcely  appreciable  cithitus 
vnnix.  This  patient  did  not  apply  for  treatment  until  two  days  after 
the  in|iir\-. 

FRACTURES  OF  THE  EPITROCHLEA. 

There  are  onh'  i,  instances  ot  this  fracture  in  m\'  series  of  recent  injuries 
(Cases  42,  43,  and  44).  The  ages  of  the  patients  were  twelve,  twelve,  and 
fourteen  years.  I  have  seen  a  number  of  cases  of  old  fractures  of  the 
epitrochlea,  in  addition  to  the  three  recent  fractures,  and  think  it  must 
often  be  overlooked  by  the  patient  as  well  as  by  his  physician.  Mouchet 
encountered  it  in  nearlv  19  per  cent,  of  his  elbow  injuries. 

The  epiphyseal  centre  for  the  epitrochlea  leads  a  more  or  less  inde- 
pendent existence,  not  uniting  with  the  other  epiphyseal  centres,  but 
joining  directly  with  the  diaphysis  at  about  eighteen  vears  of  age;  hence 
it  is  more  liable  to  be  detached  up  to  this  age. 

Mechanism. — The  injury  usually  is  in  the  nature  of  a  sprain  fracture, 
the  prominent  tubercle  being  torn  of!"  In  a  sudden  strain  thrown  on  the 
muscles  attached  to  it,  and  on  the  internal  lateral  ligament.  In  two 
of  ni\'  recent  cases  the  injury  followed  a  fall  on  the  outstretched  hand, 
which  caused  h\perextension  of  the  elbow  and  sudden  abduction  of  the 
forearm  at  the  elbow;  in  the  third  patient  it  followed  a  fall  directly  on 
the  acutel)-  flexed  elbow,  thus  being  caused  by  direct  violence,  or  possibly 
being  produced  by  an  outward  strain  on  the  ulna  which  expended  its 
force  on  the  epitrochlea  through  the  internal  lateral  ligament.  In  Case  44 
posterior  luxation  of  the  ulna  also  was  produced,  as  well  as  an  injury 
to  the  olecranon;  the  latter  probably  occurred  as  a  compression  fracture, 
as  the  violent  hyperextension  of  the  elbow,  causing  the  dislocation, 
crammed  the  olecranon  into  the  olecranon  fossa.  The  fracture  of  the 
olecranon  certainly  was  not  produced  b\-  direct  violence,  as  the  boy 
fell  on  his  outstretched  hand,  and  as  it  is  inconceivable  that  posterior 
luxation  of  the  ulna  could  be  produced  by  a  fall  on  the  olecranon. 

Symptoms. — Very  little  serious  disability  follows  this  injury,  and  it 
IS  often  neglected,  being  treated  as  a  sprain.  On  examination,  besides 
localized  swelling,  and  on  the  second  or  third  dav  ecchymosis  over  the 
inner  aspect  of  the  elbow,  the  surgeon  can  readih'  detect  the  separation 
of  the  epitrochlea  by  its  mobilit\',  and  b\-  producing  crepitus  by  rubbing 
this  detached  fragment  against  the  shaft.  The  motions  of  the  elbow- 
joint  are  not  afl-'ected,  though  full  extension  is  painful.  Usuall\-  enough 
fibres  of  the  internal  lateral  ligament  remain  intact  to  prevent  an\-  lateral 
mobilit\'  of  the   )oint. 

Pathological  Anatomy. — The  line  of  fracture  is  wholh'  extra-articular; 
if  a  portion  of  the  internal  lip  of  the  trochlea  is  detached  also,  the  injury 


EPIPHYSEAL  SEPAR/ITIONS  79 

should  be  classed  as  a  fracture  of  the  internal  cond}le.  There  seems 
some  reason  to  believe  that  in  young  children  the  capsule  is  not  applied 
so  closely  to  the  base  of  the  inner  lip  of  the  trochlea  as  it  is  in  later  lite, 
so  that  sometimes  it  ma\-  be  possible  for  a  simple  detachment  of  the 
epitrochlea  to  open   the   joint. 

The  fragment  is  displaced  downward  and  forward  b)  muscular  action. 
Injury  to  the  ulnar  nerve  is  rare. 

Treatinent. — Immobilization  in  flexion  prfibabh'  is  sufficient.  I  em- 
ployed  in  perflexion  in  all  my  cases. 

Results. — The  patient  who  also  had  his  elbow  dislocated  cannot  be 
traced;  one  patient  recovered  with  full  flexion  and  extension  to  175  degrees 
(practically  complete);  the  carrying  angle  was  ncjt  altered;  while  in  the 
third  patient  the  result  is  classed  as  perfect.  I  have  noticed  that  though 
return  of  complete  extension  is  very  slow  even  in  patients  who  have  been 
treated  well,  it  is  very  much  slower  in  those  who  have  not  been  treated 
at  all  while  the  iniur\-  was  recent. 

EPIPHYSEAL  SEPARATIONS. 

There  are  7  such  cases  in  my  series  (Cases  45  to  51).  The  agi^s  of 
these  patients  were  two,  two,  three,  nine,  eleven,  eleven,  and  twelve 
years.  That  separation  of  the  lower  humeral  epiphysis  cannot  occur 
except  under  the  age  of  three  years,  "when  it  is  still  entirely  cartilagin- 
ous," though  it  is  a  statement  repeatedl\-  made  by  Mouchet,  I  think 
cannot  go  unchallenged.  In  the  first  place  the  epiph\'sis  is  not  "still 
entirely  cartilaginous"  until  the  age  of  three  years,  since  the  centre  for 
the  capitellum  invariably  appears  before  the  end  of  the  first  year  of  life; 
and  I  think  the  diagnosis  in  my  patients  (Cases  45,  47,  49,  and  50), 
whose  ages  varied  from  nine  to  twelve  years,  sufficiently  exact  to  show 
that  such  an  injur\-  can  occur  even  when  ossification  in  the  e]iiph\sis 
is  moderately  tar  advanced.  The  question  of  diagnosis  will  be  discussed 
with  the  symptoms. 

The  extraordinary  number  of  epiphyseal  separations  (nearly  one- 
fourth  of  the  entire  number  of  elbow  injuries)  seen  by  Chutro  is  a  matter 
of  surprise;  several  of  the  patients  whose  histories  he  relates  in  detail 
are  over  three  years  of  age  (five,  six,  eight  \ears). 

Mechanism. — This  was  not  known  or  is  not  recorded  in  4  of  my  pa- 
tients. One  patient  tell  on  to  the  extensor  surface  ot  his  flexed  forearm, 
and  two  patients  fell  on  to  their  outstretched  hands;  in  one  of  these 
latter  the  fall  produced  momentary  hyperextension  of  tiie  elbow,  but 
in  the  other  the  elbow  collapsed  into  acute  flexion. 

Symptoms. — These  resemble  those  of  a  severe  sprain  of  the  elbow, 
with  something  more  whicli  it  ma\'  be  difficult  to  recognize  as  an  entity. 


80  FRACTURES  OF  THE  ELBOIV 

Chutro  (juotes  the  statement  of  O.  WolfF:  "Manche  angebliche  Con- 
tusion des  Gelenkes  wiirde  besser  unter  der  Diagnose  Epiphysenlesion 
geflihrt." 

I  have  not  observed  the  rounded  projection  of  the  upper  fragment 
in  the  bend  of  the  elbow,  described  by  so  many  writers  as  characteristic 
of  epiphyseal  separations,  though  sometimes  the  bend  of  the  elbow  has 
seemed  fuller  than  normal.  In  the  cases  I  have  seen  there  has  been 
no  apparent  displacement,  and  no  clearly  defined  abnormal  mobility; 
and  I  have  based  my  diagnosis  on  (i)  the  severity  of  the  subjective 
symptoms;  (2)  the  persistent  localized  tenderness,  especially  apparent 
in  the  bend  of  the  elbow;  (3)  the  existence  of  moist  crepitus;  (4)  ex- 
treme pain  on  forced  extension,  which  pinches  the  fragments  in  their 
displaced  position;  and  (5)  on  the  results  of  skiagraphy  The  skiagraph 
will  exclude  any  other  injury  to  the  humerus,  and  in  some  instances 
will  give  positive  evidence  of  an  epiphyseal  separation  b\-  showing  a  small 
shell  torn  off  the  diaph\sis  just  above  the  epiph}seal  line.  For  it  is 
not  unusual  for  such  a  shell  of  bone  to  be  torn  loose  with  the  cartilage 
(Figs.  43.  I  j4,  140).  When  the  line  of  separation  passes  entirely  through 
cartilage,  as  it  frequently  does,  it  will  not  be  visible  in  a  skiagraph,  as 
the  cartilage  bordering  the  line  of  fracture  will  be  quite  as  pervious  to 
the  X-rays  as  the  line  of  fracture  itself  (page  42);  in  such  a  case  the  diag- 
nosis must  be  made  from  the  clinical  symptoms  alone.  Thus  in  Case 
48  the  skiagraph  showed  absolutely  no  abnormality ;  and  if  the  clinical 
symptoms  had  been  disregarded  the  injury'  would  have  been  classed  as 
a  sprain.  But  the  subsequent  development  of  cubitus  valgus  confirmed 
the  clinical  diagnosis  by  showing  that  there  had  been  a  severe  injury 
to  the  epiphyseal  cartilage. 

Patfiological  Anatomy. — Tlie  reason  that  this  lesion  is  more  frequent 
among  young  than  older  children  is  that  as  age  progresses  the  diaphysis 
grows  downward  toward  the  epiphysis,  especially  in  the  region  between 
the  centres  for  the  capitellum  and  the  trochlea,  as  noted  at  page  32 
(Fig.  22);  the  consequence  being  that  the  epiphysis  is  strengthened  by 
this  spur  of  bone  yvhich  grows  down  into  it,  and  is  therefore  less  liable 
to  be  torn  loose. 

The  detached  fragment  is  wholly  or  in  large  part  intra-articular.  The 
joint  cavity,  as  seen  in  Fig.  5,  extends  to  above  the  coronoid  and  radial 
foss.Te;  while  the  epiphyseal  line  lies  distinctly  below  this  point,  a  shell 
of  the  diaph)sis  separating  it  from  these  fossae  (Fig.  18).  If  the  epi- 
trochlea  and  epicondyle  are  detached  along  with  the  cartilage  which 
goes  to  form  the  trochlea  and  capitellum,  then  the  detached  portion 
will  be  partly  intra-  and  partly  extracapsular. 

Displacement  usually  is  slight,  as  the  capsule  is  not  widely  ruptured. 
The  injury  partakes  more  of  the  nature  of  a  recent  case  of  "internal 


FRACTURES  OF  THE  INTERNAL  CONDYLE  81 

derangement  of  the  knee-joint"  where  a  piece  ot  the  articular  cartilage 
has  been  chipped  oft"  by  sudden  and  abnormal  pinching  between  the  ends 
of  the  bones. 

Treatment. — The  hyperflexed  position  lias  been  employed  in  ail  my 
cases,  though  I  do  not  think  it  so  important  m  tliese  as  in  supracondylar 
and  transverse  diacondylar  fractures.  Immobilization  at  a  right  angle 
probably  would  answer  as  well,  but  is  not  so  comfortable  to  the  patient; 
and  some  motion  is  apt  to  persist  in  the  elbow-joint  except  when  it  is  in 
hyperflexion. 

Results. — Of  the  7  patients,  2  cannot  be  traced;  the  result  in  4  is  classed 
as  perfect;  while  in  i  patient  (Case  48),  though  flexion  is  complete, 
extension  is  limited  to  170  degrees,  and  there  is  slight  cubitus  valgus. 

FRACTURES  OF  THE  INTERNAL  CONDYLE. 

There  are  only  four  cases  of  this  injury  in  my  series  (Cases  52  to  55). 
The  ages  of  the  patients  were  two,  fourteen,  seventeen,  and  fort\-two 
years,  including  two  out  of  the  three  adults  in  the  entire  series,  the  third 
adult  (Case  56)  having  suffered  an  intercondylar  fracture.  It  is  one 
of  the  rarest  injuries  around  the  elbow-joint.  Chutro  saw  it  only  twice 
among  106  cases,  and  Mouchet  only  once  among  170.  Kocher  observed 
6  fractures  of  the  internal  condyle  among  45  fractures  of  the  lower  end 
of  the  humerus,  but  in  two  the  diagnosis  was  uncertain.  In  two  of  my 
own  cases  the  diagnosis  is  not  positive,  as  I  have  no  notes  ot  the  symp- 
toms, and  no  skiagraphs  demonstrating  the  nature  of  the  injury;  one 
ot  these  patients  (Case  52)  came  under  observation  only  two  weeks 
after  the  injury. 

Owing  to  the  teaching  of  Allis,  and  afterward  to  the  work  of  Davis, 
it  was  long  believed  that  this  was  one  of  the  most  trequent  fractures; 
but  as  both  these  observers  based  their  opinion  on  the  great  number 
of  cases  of  gunstock  deformity  they  had  seen,  it  was  merely  assumed 
that  the  preceding  injury  in  most  of  the  cases  had  been  fracture  of  the 
internal  condyle.  Cotton  contended,  and  I  believe  with  perfect  justice, 
that  supracondylar  fracture  was  the  chief  cause  of  subsequent  gun- 
stock  detormit\";  not  because  fractures  of  the  internal  condyle  are  not 
exceedingly  prone  to  give  rise  to  this  deformity,  but  simply  because  the 
total  number  of  supracondylar  fractures  observed  so  greatly  exceeds 
those  of  the  internal  condyle  alone.  Cotton  in  his  own  series  of  32  cases 
had  none  of  fractures  of  the  internal  condyle;  yet  he  obtained  11  cases 
ot  cubitus  varus,  and  i  of  cubitus  valgus,  among  27  cases  traced.  Coenen 
had  7  cases  of  varus  and  i  of  valgus  among  28  cases  of  supracond\lar 
fracture  which  he  traced.  Hilgenreiner,  among  14  supracondylar  frac- 
tures traced,  found  4  with  varus,  and  i  with  valgus  deformit\'. 
6 


82  FRACTURES  OF  THE  ELBOIV 

Mechanism. — This  is  not  nottcl  in  the  two  cases  in  which  the  diag- 
nosis is  uncertain;  in  both  the  other  patients  the  injury  was  received 
by  a  fall  on  the  point  of  the  acutely  flexed  elbow.  Evidently  either 
the  ulna  came  into  contact  with  the  ground,  and,  im|:)inging  on  the 
trochlea,  split  off  its  inner  lip  and  the  epitrochlea  all  in  one  piece,  or 
else  the  fracture  was  produced  b\'  direct  violence  acting  on  the  epi- 
trochlea; the  former  is  certainly  much  more  probable.  This  is  gen- 
erally admitted  to  be  the  most  frequent  mechanism;  and  as  children 
usually  fall  upon  the  outstretched  hand,  the  raritv  of  this  injur\-  is 
easih'  explained. 

Symptoms. —  1  here  usuallv  is  loss  of  the  carr\ing  angle,  the  weight 
of  the  forearm  causing  it  to  swing  inward  at  the  elbow,  like  a  pendulum, 
when  the  support  of  the  internal  cond\le  is  removed.  Crepitus  is  easily 
detected  by  adduction  and  abduction  of  the  forearm,  and  b\'  moving 
the  internal  condyle  antero-posteriorly  on  the  shaft  of  the  humerus. 
The  injury  to  the  soft  parts  trequenth  is  more  severe  than  in  the  usual 
run  of  elbow  fractures. 

Pathological  Anatomy. — The  line  ot  fracture  invariabh'  extends  into 
the  joint,  passing  from  above  the  epitrochlea  (on  the  internal  supra- 
condylar ridge)  down  to  the  trochlear  surface  of  the  elbow-joint.  If 
the  epitrochlea  alone,  or  the  trochlea  alone,  is  detached  the  lesion  should 
not  be  classed  as  a  fracture  of  the  internal  condyle;  for  although  the 
trochlea  and  epitrochlea  are  parts  of  the  internal  cond\le,  to  speak  of 
such  lesions  as  fractures  of  the  internal  condyle  without  qualif\ing  the 
expression  in  any  way  is  as  misleading  as  it  would  be  to  classif)'  fractures 
of  the  nasal  bones  among  fractures  of  the  skull. 

The  line  of  fracture  may  enter  the  joint  just  to  the  radial  side  of  the 
prominent  inner  lip  of  the  trochlea,  as  in  Case  53  (Fig.  145),  or  in  the 
middle  of  the  trochlea,  as  shown  in  Fig.  44,  or  even  in  the  neighborhood 
of  the  capitellum. 

This  probably  is  the  most  disabling  of  fractures  around  the  elbow. 
The  ulna  is  the  main  constituent  of  the  forearm,  being  the  anatomical 
continuation  of  the  humerus,  while  the  radius  belongs  to  the  hand. 
Consequently,  fracture  of  the  internal  cond\le,  interfering  with  the 
continuity  between  the  humerus  and  ulna,  practicalh'  abolishes  the 
functions  of  the  forearm.  The  further  the  line  of  fracture  extends 
toward  the  capitellum  the  more  completeh'  does  the  elbow  assume  the 
character  of  a  ball-and-socket  joint  (page  21),  the  forearm  swinging 
freely  in  all  directions — forward,  backward,  inward,  and  outward. 

When  the  forearm  is  flexed  for  examination,  the  fragment  usually 
is  found  to  be  drawn  forward  by  the  muscles  attached  to  it;  but  in  the 
extended  position  downward  displacement  is  not  noticeable,  as  the  weight 
of  the  forearm  causes  loss  of   the  carrying  angle,  and   the  consequent 


FRACTURES  OF  THE  INTERNAL  CONDriE 


83 


adduction  of  the  forearm  is  rather  incHned  to  force  the  internal  condyle 
upward. 

As  the  fracture  usually  is  caused  by  great  violence,  axial  rotation  of 
the  fragment  is  not  unusual,  and  injury  of  the  ulnar  nerve  may  occur. 
This  injury  should  be  looked  for  when  the  patient  is  first  examined; 
if  discovered  only  at  the  second  dressing,  the  patient  may  suspect  that 
the  ulnar  paralysis  was  caused  by  the  surgeon  in  setting  the  fracture, 
or  by  the  form  of  dressing  employed.  In  Case  53  complete  rotation 
of  the  fragment  occurred,  but  there  was  no  trace  of  injury  to  the  nerve. 
In  some  cases  the  fracture  is  subperiosteal,  and  no  displacement  exists 
(Fig.  45)- 


Fig.  65. — Skiagraph  of  old  fracture  of  elbow,  showing  cubitus  varus  from  ascent  of 
internal  condyle  (antero-posterior). 


Treatment. — I  have  treated  all  my  patients  in  the  position  of  hyper- 
flexion.  Ascent  of  the  fragment  is  the  chief  obstacle  with  which  the 
surgeon  has  to  contend;  and  if  ascent  of  the  fragment  is  present,  loss 
of  the  carrying  angle  will  result,  as  the  articular  surface  of  the  humerus 
will  lose  its  normal  obliquity,  and  will  come  to  lie  in  a  plane  at  right 
angles  with  the  long  axis  of  the  bone,  or  in  severe  cases  will  even  incline 
inward. 

In  the  fully  extended  position  ascent  of  the  fragment  is  caused  by  the 
force  of  gravity,  which  adducts  the  forearm.  It  is  true  that  this  may  be 
prevented  bv  the  use  of  a  suitable  splint,  applied  to  the  anterior  surface 
of  the  fullv  extended  limb,  and  made  to  conform  to  the  natural  carrying 


84 


FRACTURES  OF  rUE  ELIiOII' 


angle.  IJut  even  thus  the  constant  tendency  is  for  the  forearm  to  be 
addiicted,  causing  the  humeral  portion  of  the  splint  to  deviate  outward 
as  the  forearm  portion  is  carried  inward.  Moreover,  displacement  from 
muscular  action  is  favored,  because  the  fragment  is  not  fixed  against 
the  shaft;  the  muscles  attached  to  the  epitrochlea  tend  to  rotate  the 
fragment  around  a  transverse  axis,  thus  keeping  it  flexed  on  the  ulna; 
and  if  the  forearm  is  in  any  position  except  that  of  full  flexion  the  action 
of  the  triceps  will  displace  the  fragment  if  its  relation  to  the  sigmoid 
cavity  of  the  ulna   is  jireserved.      Dressing  the  forearm  in  full  extension 


Fig.  66. — Skiaj;raph  of  old  fracture  of  elbow,  showing  upward  displacement  of  ulna  (lateral). 

tends  to  make  the  internal  cond\le  grow  fast  to  the  humerus  "end  on;" 
the  normal  anterior  projection  of  the  articular  surface  (Fig.  i)  will  not 
be  preserved. 

Dressing  the  elbow  on  a  splint  at  right  angles  is,  if  possible,  still  more 
objectionable  than  the  extended  position.  When  an  anterior  angular 
splint  is  applied,  as  pointed  out  by  Allis,  it  tends  to  bring  the  bones 
of  the  forearm  into  the  same  plane.  In  discussing  fractures  of  the 
external  cond\le  it  was  noted  that  this  dressing  tended  to  depress  the 
radius,  and  with  it  the  external  cond\le,  to  the  same  level  as  the  ulna; 
in  the  case  of  fractures  of  the  internal  cond\le  the  radius  is  the  fixed  point 


FRACTURES  OF  THE  INTERNAL  CONDTLE  85 

of  support,  and  both  bandages  and  sling  tend  to  elevate  the  ulna,  and 
with  it  the  internal  condyle,  to  the  level  of  the  radius.  Figs.  65  and  66 
show  these  alterations  very  well.  Fig.  65  is  an  antero-posterior  view  of 
an  old  fracture  of  the  lower  end  of  the  humerus  in  which  the  trochlear 
surface  of  the  humerus  has  assumed  a  higher  position  than  the  capi- 
tellum,  with  the  resulting  cubitus  varus  shown  in  the  skiagraph;  Fig. 
66  is  the  lateral  view  of  another  old  fracture  of  the  lower  end  of  the 
humerus,  in  which  marked  cubitus  varus  resulted,  owing  to  the  ascent 
of  the  ulna,  which  is  seen  in  the  skiagraph  to  occupy  a  higher  plane 
than  does  the  radius  (compare  Fig.  24). 

Moreover,  when  the  elbow  is  dressed  on  an  anterior  or  on  an  internal 
angular  splint  the  forearm  is  more  or  less  in  the  sagittal  plane  when  the 
dressing  is  applied;  but  when  it  is  rotated  inward  so  as  to  be  carried  in 
a  sling,  it  is  quite  possible  for  the  relation  of  the  internal  condyle  to  the 
shaft  to  be  so  altered  as  to  give  rise  to  subsequent  deformity. 

In  the  position  of  hyperflexion,  on  the  contrary,  the  internal  condyle 
cannot  ascend,  because  it  has  the  whole  weight  of  the  forearm  acting 
on  it  through  the  ulna  to  hold  it  down;  it  cannot  be  displaced  backward 
because  the  tense  triceps  guards  against  this;  and  in  this  position  the 
flexor  group  of  muscles  is  relaxed  so  that  no  rotation  of  the  fragment 
around  a  transverse  axis  need  be  feared.  The  triceps,  in  this,  as  in  all 
the  fractures  of  the  lower  end  of  the  humerus  so  tar  considered,  acts  as 
the  best  splint,  surrounding  the  internal  condyle  behind,  and  below;  and, 
by  its  insertion  into  the  ulna  and  by  its  fibrous  expansion  to  the  external 
condyle  and  forearm,  supports  it  also  laterally  and  anteriorly.  It  is 
important,  however,  in  apphing  the  dressing  to  maintain  the  elbow  in 
hyperflexion,  to  take  care  that  it  is  applied  while  the  arm  and  forearm 
maintain  their  normal  relations  as  regards  the  sagittal  plane  (Fig.  17). 
If  the  humerus  is  kept  in  the  anatomical  position  (rotated  neither  exter- 
nally nor  internally),  and  the  forearm  is  then  flexed  upon  it  in  the 
sagittal  plane  and  is  then  bandaged  to  the  humerus  in  that  position 
before  the  hand  is  slung  around  the  neck,  there  will  be  little  chance  of 
causing  cubitus  varus. 

If  replacement  of  the  fragment  is  impossible  by  manipulation,  an 
incision  should  be  made,  the  fragment  replaced  and  held  in  place,  if 
possible,  by  periosteal  sutures.  Operative  treatment  is  also  indicated 
in  cases  of  primary  injury  to  the  ulnar  nerve. 

Results. — My  first  patient  (Case  52)  cannot  be  traced.  The  second 
(Case  53)  recovered  with  full  flexion,  extension  to  150  degrees,  and  slight 
cubitus  valgus,  as  seen  in  Fig.  146.  The  third  patient  (Case  54),  a  child 
of  two  years,  in  whom  the  diagnosis  is  uncertain,  recovered  with  perfect 
functions  and  no  deformit\';  while  in  the  last  case  the  result  was  equally 
good. 


86  FRACTURES  OF  THE  ELBOfV 


INTERCONDYLAR  FRACTURES. 


From  a  personal  experience  f)f  only  one  atypical  case  (Case  56)  it  is 
impossible  to  say  much  of  this  rare  variety  of  fracture.  1  have  seen 
a  numlier  of  so-called  T-fractures  under  the  care  of  other  surgeons, 
but  have  never  been  able  to  satisfy  myself  hv  personal  investigation 
that  the  injury  really  was  such  as  diagnosticated.' 

Mechanism. — It  usualh-  is  caused  b\'  direct  violence,  with  considerable 
injury  ot  the  soft  parts.  It  is  possible  that  the  ulna  may  act  as  a  wedge 
in  falls  upon  the  flexed  forearm,  splitting  the  condyles  off  the  shaft 
(Madelung's  theory).  Gurit  held  that  a  supracond\lar  fracture  was 
first  produced,  and  that  the  diaphysis  of  the  humerus  then  acted  as  a 
wedge  in  driving  the  condyles  apart. 

Symptoms. — The  fracture  often  is  compound,  and  the  patients  usually 
must  be  confined  to  bed  for  some  days  at  least.  It  is  least  rare  in  adults. 
Owing  to  the  condition  of  the  soft  parts  and  the  extraordinar\'  amount 
of  swelling,  palpation  is  of  limited  value;  but  in  t\  pical  cases  the  breadth 
of  the  elbow  is  much  increased,  the  condyles  having  a  marked  tendency 
to  be  separated  by  the  shaft  of  the  humerus,  which  sinks  in  between 
them.  The  ulna  may  seem  to  ascend  between  the  condyles.  A  lateral 
skiagraphic  view  showing  the  upward  displacement  of  the  ulna  gives 
a  typical  picture.  Chutro  reproduces  one  such  skiagraph.  Crepitus 
is  readily  detected,  and  the  joint  is  more  or  less  Bail-like. 

Pathological  Anatomy. — From  the  descriptions  given  of  these  rare 
fractures,  it  is  evident  that  while  the  tvpe  conforms  in  general  to  the 
T,  Y,  or  V-shape,  yet  the  fragments  often  are  irregular  in  outline,  and  the 
displacement  varies  so  much  that  no  definite  description  of  it  can  be 
given. 

Treatment. — In  many  cases  operative  treatment  is  indicated.  By 
means  of  two  lateral  incisions  the  integrity  of  the  ulnar  and  radial  nerves 
can  be  ascertained,  loose  splinters  removed,  and  the  condyles  fixed  by 
periosteal  sutures,  or  even  b\'  long  nails  (Roberts). 

In  simple  cases  (those  which  can  be  treated  without  operation),  I 
should  be  inclined  to  prefer  any  position  (except  full  extension)  which 
seemed  to  hold  the  fragments  best  in  place.  Some  surgeons  recommend 
the  position  of  hyperflexion.  but  it  should  be  remembered  that  where 
both  cond)'les  are  broken  off  the  tension  put  upon  the  triceps  in  that 
position  will  only  drive  the  shaft  of  the  humerus  more  deeph'  between 
the  condyles,  except  in  the  case  of  a  true  T-fracture,  when  the  end  of 

'  Since  writing  the  above,  I  have  examined  one  case  of  T-fracture  (diagnosis  confirmed 
by  skiagraph)  under  the  care  of  my  colleague,  Dr.  E.  G.  Alexander,  at  the  Episcopal 
Hospital. 


COMPLIC.ITIONS  87 

the  humerus  is  fractured  transversely.  Perhaps  employing  an  anterior 
angular  splint  with  weight  extension  just  helow  the  elhow  might  suffice 
to  keep  the  concl\  les  clown  where  the\-  helong,  though  it  certainl\-  would 
he  apt  to  give  rise  to  gunstock  deformitN  ;  hut  alter  all,  this  is  a  less  evil 
than  a  stiff  elhow. 

In  the  onl\-  case  under  my  care,  which  was  at  first  diagnosticated  as 
fracture  of  the  internal  condyle,  the  position  of  hyperflexion  was  used; 
an  antero-posterior  skiagraph  (Fig.  150),  made  three  weeks  after  the 
injur\,  showed  also  an  impacted  fracture  of  the  external  condyle. 

Results. — In  the  case  under  my  care  full  flexion  and  extension  were 
present  at  the  end  of  three  weeks,  but  there  was  slight  gunstock  defor- 
mity. It  has  been  impossible  to  trace  this  patient  farther.  Certainly, 
in  typical  intercond\lar  fractures  the  prognosis  should  be  guarded; 
for,  though  a  fair  range  of  motion  may  be  obtained,  it  is  almost  impos- 
sible to  prevent  a  certain  amount  of  deformity. 


COMPLICATIONS. 

The  chief  complications  encountered  in  fractures  of  the  lower  end  of 
the  humerus  are  Volkmann's  isch;emic  contracture,  injuries  to  the  nerves, 
especially  the  ulnar  and  median,  and  occasionally  lesions  of  the  blood- 
vessels. The  only  complication  met  with  in  the  present  series  of  56 
cases  was  a  neuritis  of  the  median  nerve  (Case  11),  due  to  its  being 
stretched  over  the  projecting  end  of  the  upper  fragment.  This  was 
relieved  by  operation,  the  projecting  bone  being  chiselled  off,  and  flaps 
of  fascia  sutured  beneath  the  nerve.  Among  31  cases  of  supracond\lar 
fracture  Coenen  observed  three  cases  of  musculospiral  paralysis;  this 
has  also  been  seen  by  Chutro.  Mouchet  has  observed  cases  of  ulnar 
paralysis  occurring  in  adults,  due,  he  thinks,  to  the  gradual  increase  of  a 
cubitus  valgus  resulting  from  a  fracture  of  the  external  condyle  in  child- 
hood. Destot,  Vignard,  and  Barlatier,  among  72  elbow  fractures,  ob- 
served one  case  each  of  musculospiral  and  of  median  paralysis,  both 
patients  recovering  without  operation;  they  say  (p.  155)  that  Broca 
and  Mouchet  reported  9  cases  with  nerve  injury  among  78  elbow  frac- 
tures, and  that  Miiller  claimed  that  nerve  complications  occur  in  one- 
fifth  of  cases  of  supracondylar  fracture. 

Coenen  had  one  case  of  ischaemic  contracture  among  his  31  recent 
supracond\lar  fractures.  Several  instances  of  this  deformit\-  have 
come  under  my  observation,  following  fractures  of  the  elbow  treated 
by  others.  As  noted  recently  by  J.  J.  Thomas,  ner\e  changes  are  almost 
always  present  as  well,  and  the  condition  is  difiicult  to  distinguish  from 
cases  of  ulnar  neuritis. 


88  FRACTURES  OF  THE  EEBOJV 

Vascular  lesions  and  other  serious  injiuies  of  the  soft  parts  are  seldom 
observed  unless  the  fracture  is  compound. 

I  have  seen  two  cases  of  ununited  fracture  of  the  external  condyle. 
Sir  Astley  Cooper  {Dislocations,  Plate  XXV)  gives  an  illustration  of  such 
a  lesion. 

DRESSING  THE  ELBOW  IN  HYPERFLEXION. 

The  term  hvpcrflexion  is  employed  in  this  paper  because  it  has  been 
objected  to  the  term  "  acute  flexion"  that  any  angle  less  than  a  right 
angle  was  acute,  and  that  the  term  therefore  was  not  sufficiently  de- 
scriptive of  the  position  advocated  by  Jones,  of  Liverpool^  and  others. 
According  to  Chutro  (loc.  cit.,  p.  158),  it  was  Dauvergne  who,  in  1873, 
first  suggested  the  position  of  hyperflexion  for  fractures  of  the  lower  end 
of  the  humerus.  He  urged  flexion  so  acute  that  the  hand  touched  the 
shoulder  of  the  injured  arm;  in  this  way,  he  argued,  the  bones  of  the 
forearm  themselves  acted  as  an  anterior  splint,  and  he  considered  none 
other  necessary.  About  fifteen  years  ago  the  position  began  to  be 
known  by  the  names  of  Jones  and  of  Smith.  Mr.  Jones,  so  far  as  I 
have  been  able  to  ascertain,  received  the  idea  from  his  late  master,  Hugh 
Owen  Thomas,  who  had  employed  the  position  of  acute  flexion  after 
excisions  of  the  elbow  for  tuberculous  disease.  H.  L.  Smith  was  also 
an  early  advocate  of  this  position  for  fractures  about  the  elbow. 

A  very  usual  mistake,  I  find,  is  to  confuse  Velpeau's  position  with 
that  which  I  prefer  to  call  hyperflexion.  In  the  former,  the  hand  of  the 
injured  extremity  reposes  on  the  opposite  shoulder,  and  the  elbow  is  flexed 
to  approximately  45  degrees;  this  certainly  is  "  acute"  flexion.  But  in  the 
position  of  hyperflexion  the  forearm  is  flexed  upon  the  arm  as  far  as  it 
will  go  without  causing  arrest  of  the  radial  pulse;  the  hand  of  the  injured 
extremity  frequently  can  be  brought  to  its  own  side  of  the  neck;  and 
always  the  thumb  of  the  hand  should  be  able  to  lie  comfortably  on  the 
same  side  of  the  neck  as  the  injured  limb.  In  hyperflexion  the  elbow 
is  at  an  angle  of  30  degrees  or  less,  sometimes  at  20  degrees;  this 
depends  somev^'hat  upon  the  amount  of  subcutaneous  fat,  oedema,  etc. 
I  have  never  seen  a  recent  uncomplicated  fracture  of  the  lower  end  of 
the  humerus  in  which  the  swelling  was  so  great  as  to  prevent  the 
employment  of  this  position. 

It  gives  me  pleasure  to  take  this  opportunit\  to  thank  Dr.  J.  H. 
Gibbon,  who  was  at  the  time  (1900)  my  chief  at  the  Children's  Hospital 
of  Philadelphia,  tor  first  calling  my  attention  to  "  Jones's  position"  in 
the  treatment  of  these  injuries.  At  the  time  I  was  skeptical  of  its 
value.  Further  experience,  and  especially  an  application  of  increasing 
anatomical  knowledge  to  the  injuries  observed,  has  demonstrated  to  my 


DRESSING  THE  ELBOlf  IN  I D' I'ERFI.EXION 


89 


satisfaction  its  superiority  over  any  other  position;  and  in  consequence 
I  have  been  able  to  treat  such  fractures  with  a  confidence  and  satisfac- 
tion, both  to  patients  and  surgeon,  which  I  had  previously  beheved  to 
be  unattainable. 

To  maintain  the  position  of  hvperflexion  I  employ  nothing  but  a  roller 
bandage.  A  fold  of  lint,  with  some  dusting  powder,  is  placed  in  the 
crease  of  the  elbow,  to  prevent  maceration  of  the  apposed  surfaces,  and 
any  abrasions,  bulhe,  etc.,  are  suitably'  dressed.  Then  the  fracture  is 
set,  by  combined  hvperextension,  manipulation,  and  traction,  as  indicated, 
and  with  the  humerus  in  the  anatomical  position  the  forearm  is  hyper- 


^■F^^'-  1 

r^H 

^H 

■^1 

i 

J 

Jf^   L 

/  j^^H 

L^ 

»^^ 

Fig.  67. — Dressing  to  maintain  elbow  in 
hyperflexion,  first  stage. 


Fig.  68. — Dressing  to  maintain  elbow 
in  hyperflexion,  second  stage. 


flexed  upon  the  arm  exacth'  in  the  sagittal  plane,  or  inclining  slightly 
outward  (abduction  of  the  forearm),  as  1  regard  cubitus  valgus  as  less  of 
an  evil  than  cubitus  varus.  The  forearm  is  now  held  precisely  in  this 
position,  regardless  of  whether  its  bones  are  supinated  or  pronated,  and 
the  application  of  the  roller  bandage  is  commenced,  after  ascertaining 
that  the  radial  pulse  has  not  been  obliterated.  Starting  with  several 
circular  turns  around  the  wrist,  the  hand  is  next  carefulh*  covered  in; 
I  have  seen  neglect  of  this  precaution,  in  cases  treated  by  other  surgeons, 
lead  to  alarming  swelling  of  the  unsupported  hand.  When  the  roller 
again  reaches  the  wrist,  it  is  carried  directly  across  to  the  upper  arm, 


90 


FRACTURES  OF  TIIF  ELROIF 


as  close  as  possihk-  to  rhc  axilla,  and,  passing  under  and  iiiound  the  arm, 
is  again  returned  to  the  wrist  (Fig.  67).  This  first  turn  around  the  arm 
may  be  drawn  tairl\-  tight,  as  the  precaution  to  commence  the  bandage  by- 
several  turns  around  the  wrist  has  placed  a  pad  of  such  thickness  over 
the  ulna  that  injurious  pressure  on  its  subcutaneous  surface  need  not  be 
feared.  Neglect  to  commence  the  bandage  by  sufficient  circular  turns 
around  the  wrist,  in  one  case  of  which  I  have  knowledge,  resulted  in  a 
slough  forming  at  this  point.  The  bandage  is  then  continued  as  shown 
in  Fig.  68,  covering  in  the  elbow  as  an  amputation  stump.  The  humerus 
may  be  freeh'  abducted  from  tlie  bodv  durmg  the  bandaging,  when  once 


Fig.  6g. — Dressing  to  maintain  elbow  in  hvperflexion,  completed. 

the  forearm  has  been  fixed  to  it  b\-  one  or  two  circular  turns,  as  there- 
after no  movement  in  the  elbow  can  take  place  whether  the  humerus  is 
moved  or  not.  Finallv,  the  surgeon  returns  the  roller  to  the  wrist,  and, 
without  cutting  the  roller,  bandages  the  wrist  to  the  neck  by  one  or  two 
turns,  internal  rotation  of  the  humerus  and  forearm  eii  masse  taking  place 
as  this  manipulation  is  accomplished  (Fig.  69).  If  one  roller  bandage  is 
not  sufficient,  use  two;  it  is  alwa\s  better,  in  fractures,  to  use  too  many 
bandages  than  too  few;  and,  as  long  ago  taught  by  Hippocrates,  the 
outer  bandages  may  be  applied  more  snuglv  than  the  primar\'  roller. 

The  elbow  and  arm  are  never  bandaged  to  the  chest.     The  child  may 
wag  its  immovably  fixed  elbow  all  it  wants  to,  abducting  and  adducting 


DRESSING  THE  ELBOIV  IN  HYPRRFI.EXION  91 

the  hunicrus  as  much  as  it  pleases;  //  cinmot  Jistiirh  tin-  position  of  the 
Jragiiients  without  first  overcoming  the  hypcrfiexion. 

An  undershirt  may  be  slipped  under  the  bandaged  elbow;  and  by 
abducting  the  arm  the  axilla  is  freely  opened  for  washing,  powdering, 
etc.  The  back  of  the  neck,  if  irritated  by  the  bandages,  may  be  pro- 
tected by  a  piece  of  lint,  folded  to  make  a  collar,  the  bandages  being 
passed  through  safet\-pins  as  the  reins  pass  through  the  terrets  on  the 
horse's  harness;  usually  washing  the  neck  with  alcohol,  and  the  use  o\ 
a  dusting  powder,  makes  such  devices  unnecessary. 

The  patient,  or,  if  a  child,  his  caretaker,  is  cautioned  to  observe  the 
fingers  from  time  to  time,  and  to  report  any  swelling  at  once.  I  have 
never  had  an\-  inconvenience  on  this  account.  Invariably  the  patient  is 
seen  the  next  da\'  after  setting  the  fracture,  but  if  the  dressing  is  comfort- 
able it  is  not  disturbed.  So  often  I  have  obser\ed  pain  and  swelhng 
subside  in  a  few  hours  after  dressing  these  fractures  in  hyperflexion, 
that  it  ceases  to  be  a  surprise  that  patients  prefer  this  position  to  the  use 
of  a  right-angled  splint. 

On  the  third  or  fourth  day  after  the  in]ur\  the  bandage  is  cut,  and 
while  the  position  of  h\  perflexion  is  carefully  and  unremittingly  main- 
tained by  the  surgeon,  the  hand,  forearm,  arm,  axilla,  and  elbow  are 
thoroughly  washed  with  alcohol;  then  the  hyperflexion  is  cautiously 
diminished  just  enough  to  enable  the  surgeon  to  bathe  the  flexure  ot 
the  elbow  and  to  insert  a  new  piece  of  lint.  The  h\perflexion  is  then 
reproduced,  and  the  roller  bandage  applied  as  before. 

The  elbow  is  dressed  twice  weekh',  and  the  position  of  h\perflexion 
is  maintained  for  over  two  weeks.  Then  the  degree  of  flexion  is  grad- 
ually diminished  at  each  dressing,  no  splint  ever  being  used,  but  extension 
beyond  65  or  70  degrees  being  prevented  by  a  figure-of-eight  bandage 
around  the  elbow;  and  the  wrist  is  still  suspended  from  the  neck.  At 
the  end  of  four  weeks  the  extension  has  reached  90  degrees,  and  the 
arm  is  carried  in  a  large  triangular  sling,  preventing  further  extension 
for  a  week  longer.  At  the  end  of  five  weeks  the  sling  is  discarded,  and 
use  of  the  arm  is  encouraged.  Passive  movements  are  never  enforced. 
Occasionally,  by  abducting  the  humerus  to  a  right  angle  and  allowing 
the  forearm  to  hang  vertically  downward,  it  is  swa\ed  genth'  back  and 
forth  as  a  pendulum;  but  no  direct  passive  motion  is  emplo}ed,  nor 
massage. 

Some  patients  secure  complete  extension  in  the  sixth  week  (Cases 
8,  9,  55);  others  do  not  secure  it  for  six  months  or  a  year  (Cases  6,  22, 
36).  They  are  encouraged  to  carry  weights  in  the  hand,  to  use  the  arm 
in  climbing,  gymnastics,  etc.  B\'  the  use  of  the  goniometer  (Fig.  70) 
accurate  records  of  the  gradualh-  returning  extension  ma\'  be  kept, 
and    the   patient's   interest   in    returning   periodical!}'   tor  observation   is 


92 


FR.ICnrRES  OF  THE   F.IMOIV 


stimulated.     This  instrument  should  also  he  used  in  recording  the  finaF 
results. 

If  accurate  replacement  can  he  secured,  and  it  the  periosteum  has 
not  been  too  widely  stripped  from  the  hone,  there  is  no  reason  to  fear 
the  development  of  excessive  callus.  No  such  callus  is  formed  in  frac- 
tures of  the  base  of  the  skull,  nor  in  other  fractures  without  displacement. 
Long-continued  immoliilization  of  a  normal  joint  has  been  proved^ 
experimentally  and  clinically,  not  to  be  productive  of  ankylosis.  If. 
therefore,  the  surgeon  is  confident  that  he  has  reduced  a  fracture  of  the 
lower  end  of  the  humerus,  a  fact  which  can  be  proved  by  the  use  of 
the  X-rays,  there  is  no  reason  why  he  should  torture  his  patients  by 
enforcing  passive  motion.     As  a  resident  physician  in  the  hospitals,  some 


of  my  chiefs  "believed  in  the  use  of  earlv  passive  motion"  for  fractures 
around  the  elbow;  and  man\'  is  the  elbow  on  which  at  their  instigation 
I  have  enforced  violent  passive  movement  with  the  idea  of  preventing 
or  of  breaking  up  adhesions,  destroying  or  wearing  away  exuberant 
callus,  etc.  The  children  kicked,  screamed,  and  yelled;  their  parents, 
the  orderly,  and  the  nurse  held  them  still,  while  I  gave  them  excruciat- 
ing pain,  and  unwittingly  aroused  more  osteogenetic  and  inflammatory 
processes  around  the  elbow  than  were  present  before;  and  I  never  saw 
an  elbow  fracture  which  did  not  stiffen  up  under  this  treatment.  Frac- 
tures around  the  elbow  I  regarded  as  hopeless;  I  anticipated  a  stifF 
joint,  deformity,  or  at  least  a  considerable  limitation  of  motion  in  prac- 
tically every  case,  and  I  rarely  failed  to  find  it. 


RESULTS  93 

Since  then  my  eves  have  been  opened,  and  1  am  convinced  of  tlie  truth 
•of  Stimson's  epigrammatic  statement:  "  If  you  leave  the  arm  alone,  you 
save  your  time  and  the  patient's  time,  and  he  gets  well  quite  as  promptly." 

RESULTS. 

The  most  disabling  result  of  fractures  of  the  lower  end  ot  the  iiumerus 
is  ankylosis;  then  in  lessening  degree  come  grades  of  restriction  of  motion 
just  short  of  absolute  ankylosis,  up  to  a  mere  loss  of  the  power  of  full 
extension  and  full  flexion,  which  really  hinders  the  functional  use  of  the 
joint  not  at  all.  So  long  as  a  fair  range  of  motion  (say  from  50  to  150 
degrees)  is  preserved,  there  is  comparatively  little  disability.  Deformity, 
as  such,  is  rarely  disabling;  marked  degrees  of  gunstock  deformity, 
especially  cubitus  varus,  usually  weaken  the  joint,  and  thus  impair  its 
functions,  besides  making  the  patient  conspicuous.  Slight  degrees  of 
deformity,  especially  cubitus  valgus,  are  neither  evident  to  the  casual 
observer,  nor  do  they  interfere  with  the  normal  use  of  the  joint,  so  long 
as  its  motility  is  preserved. 

A  perfect  result,  as  the  term  is  here  used,  implies  one  in  which 
the  full  range  of  normal  motion  is  preserved  {flexion  as  in  the  uninjured 
elbow,  and  extension  to  at  least  180  degrees),  and  in  which  the  carrying 
angle  is  normal. 

Judged  by  these  standards  the  following  results  have  been  reported  by 
various  careful  investigators:  Coenen  traced  28  supracondylar  fractures 
of  the  humerus;  he  found  a  perfect  result  in  7  (25  per  cent.),  defective 
or  limited  motion  in  6  (21.4  per  cent.),  marked  limitation  of  motion  in 
6  (21.4  per  cent.),  cubitus  varus  in  7  (25  per  cent.),  and  cubitus  valgus 
and  Volkmann's  ischaemic  contracture  in  i  case  each. 

Cotton  traced  27  patients  with  various  fractures  of  the  lower  end  of 
the  humerus:  a  perfect  result  was  secured  in  5  ( 18.5  per  cent.),  moderate 
limitation  of  motion  in  5  (18.5  per  cent.),  marked  limitation  of  motion 
in  5  (18.5  per  cent.),  cubitus  varus  in  11  (40.74  per  cent.),  and  cubitus 
'valgus  in  i  patient  (3.7  per  cent.). 

Destot,  Vignard,  and  Barlatier  report  the  end  results  in  39  patients 
with  fractures  of  the  lower  end  of  the  humerus  as  follows:  A  perfect  result 
(under  which  term  they  include  all  cases  with  full  flexion  and  extension, 
regardless  of  whether  or  not  there  is  varus  or  valgus  deformity)  in  1 1 
cases  (28.2  per  cent.);  marked  impairment  of  function,  including  varus 
and  valgus  deformities,  in  28  cases  (71.8  per  cent.). 

Hilgenreiner  traced  14  patients:  in  3  (21.3  per  cent.)  of  these  a  perfect 
result  was  secured;  in  4  (28.57  per  cent.)  there  was  marked  limitation 
of  motion;  in  4  (28.57  per  cent,  there  was  cubitus  varus;  in  i  (7  per  cent.) 
there  was  valgus;  and  in  2  (14  per  cent.)  a  flail-joint  resulted. 


94  FR.ICTURES  OF  THE  FLBOff 

In   tlie  present  series  of   56  patients  it  has  been   possible  to  ascertain 
the  end  results  in  47  cases.     These  are  shown  in  tlie  following  table: 


End  Results  ok  Forty-seven  Cases  of  Fracture  of  the  Lower 
Extremity  of  the  Humerus. 

I 

Fracture.  Cases.  Traced.  Perfect.  motion.  V'arus.  Valgus- 

Supracondylar 21 

Diacondylar 8 

External  condyle 12 

Epitrochlea 3 

Epipfiyseal  separation      ...  7 

Internal  condyle 4 

Intercondylar i 

Total 56 

Percentage  of  those  traced     .      .  81%  8%  8%  2% 

These  results  are  compared  with  those  previously  noted  in  the  following 
table: 

Results. 


Limited 

Traced. 

Perfect. 

motion. 

V'aru: 

17 

16  (94-0%) 

I' 

8 

5  (62.5%) 

i^ 

i^ 

II 

10  (91.0%) 

,5 

2 

1  (50.0%) 

I" 

5 

4  (80.0%) 

1' 

3 

I 

2  (66.6'-;,) 

!« 

■'' 

47 

38 

4 

4 

81% 

8% 

8? 

Number  of 
Author.                   cases. 

Number 
traced. 

V 

a. 

c 

-^  .2 

S  E 

i  i 

•-§5 

u 

Cubitus 
valgus. 

Volkmann's 

ischemic 
contracture. 

Flail  joint. 

Author  of  essay 

■    56 

47 

38  (81.0^0 

4  (  8%) 

4(8%) 

I  (2.0%) 

Coenen 

•    31'° 

28 

7    (2S.O%) 

12  (43%) 

7  (25%) 

I  (3-o%)      I 

Cotton  . 

•    32 

27 

5  (■8.5':-o) 

10  (37%) 

11(40%) 

I  (3-7%) 

Destot,  Vignard, 

and  Barlatier 

3Q 

ii"(28.2':-c) 

28'-'(7i-8rc) 

Hilgenreiner      . 

.    21'" 

14 

3  (21.3%) 

4  (28.5%) 

4(28.5%) 

I                . .        2 

'  Ca.se  2  sustained  another  fracture  (diacondylar)  two  years  after  being  under  my  care, 
but  before  final  result  was  noted. 

'  Case  23.     Full  flexion,  but  extension  only  to  165  degrees. 

^  Case  24.     Diacondylar  fracture  "by  flexion."     Full  ifexion  and  extension;  cubitus  varus 
scarcely  appreciable  (Fig.   106). 

■*  Case  28.     Fracture  of  the  type  "Posadas"  (Fig.  115). 

^  Case  23-     Full  flexion,  extension  very  nearly  complete;   very  slight  cubitus  varus.      Did 
not  apply  for  treatment  until  two  days  after  injury. 

°  Case  43.     Full  flexion,  extension  to  175  degrees. 

'Case  48.     Full  flexion,  extension  to  170  degrees;   slight  valgus  (Fig.  138). 
Case  53.     Full  flexion,  extension  to  150  degrees,  and  slight  valgus  (Fig.  146). 

'  Case  56.     Full  extension,  but  slight  cubitus  varus. 

'"Only  supracondylar  fractures. 

"  Includes  ^■(•Ir^/x  and  valgus  deformities,  with  full  flexion  and  extension. 

"  Includes  varus  and  valgus  deformities,  with  limited  motion. 


RESULTS  95 

In  tlic  present  sents  there  were  no  cases  of  ankylosis;  the  greatest 
Hmitation  ot  motion  was  a  loss  ot  ^o  degrees  in  extension  (in  a  case  of 
fracture  of  the  internal  cond)le);  and  there  were  no  cases  of  ischaemic 
contracture.  One  patient  (Case  1 1)  developed  a  median  neuritis, 
which  was  promptly  relieved  by  operation.  Several  of  these  patients 
had  such  extensive  injury  of  the  soft  parts  when  first  seen  that  it  was 
not  deemed  advisable  to  treat  them  as  out-patients,  and  I  am  indebted 
to  m\'  chiefs  for  permission  to  attend  them  in  the  wards  so  long  as  it 
seemed  expedient  to  keep  them  in  the  hospital. 

As  there  appears  to  have  been  no  difference  in  the  severity  or  character 
of  the  lesions  m  these  various  series  of  cases  (so  far,  at  least,  as  one  can 
judge  from  a  study  of  the  published  case  histories  and  skiagraphs),  it 
is  not  unreasonable  to  su]ipose  that  the  much  better  results  obtained 
in  the  present  series  depend  m  some  measure  upon  the  treatmentemplo\ed. 

Possibly  the  views  held  bv  Destot,  Vignard,  and  Barlatier,  as  to  reduc- 
tion of  these  fractures,  may  be  shared  by  other  surgeons,  and  may  be 
partly  accountable  for  the  bad  results  obtained.  Speaking  of  supra- 
condylar fractures,  these  authors  ask  (loc.  cit.,  p.  176):  "  Faut-il  reduire 
d'emblee.''  La  question  ne  se  pose  pas  dans  les  cas  ou  I'enfant  vient  au 
deuxieme  ou  troisieme  ]our  apres  son  traumatisme.  Le  gonflement  est 
au  maximum  et  le  mieux  est  de  reduire  et  d'immobiliser  ensuite.  Si  la 
fracture  est  tres  recent  et  date  a  peine  de  quelques  heures,  il  est  prefer- 
able d'attendre  deux  ou  trois  jours.  Le  gonflement,  d'abord  intense,  tend 
a  diminuer,  on  peut  alors  mettre  un  appareil  definitive  sans  craindre  qu'il 
n'exerce  sur  le  menibre  des  pressions  trop  fort."  It  has  seemed  to 
me,  on  the  contrary,  that  the  most  important  thing,  if  the  case  was 
seen  early  enough,  was  to  place  the  fragments  in  accurate  apposition, 
and  by  doing  this  to  prevent  the  development  of  excessive  swelling.  I 
can  see  no  object  in  postponing  the  reduction  of  a  fracture  when  no  swell- 
ing is  present;  and  it  certainh  has  been  true  in  m\'  experience  that  those 
fractures  which  are  properly  reduced  within  a  few  hours  of  the  injury 
run  their  course  without  the  development  of  marked  inflammatorv  re- 
action in  the  soft  parts;  and  I  have  noticed,  time  and  time  again,  even 
after  the  soft  parts  had  become  greatly  swollen  before  reduction  was 
secured,  that  there  was  no  way  to  relieve  the  patient's  pain  and  to  cause 
a  diminution  of  the  swelling  so  sure  and  certain  as  complete  reduction 
of  the  bony  deformity. 

Some  of  the  observers  above  cited  have  emplo\ed  splints,  some  have 
used  plaster-of-Paris  bandages,  and  in  a  few  instances  the  elbows  have 
been  treated  in  acute  flexion. 

The  three  perfect  results  in  Hilgenreiner's  series  were  all  obtained 
after  dressing  the  elbow  in  the  position  of  acute  flexion;  the  usual  dress- 
ing was  of  plaster  of  Paris,  with  the  elbow  at  a  right  angle,  and  though 


90  FRACTURES  OF  THE  FLROW 

he  calls  the  results  ()I)taiiu(l  h\'  it  .uttisftictory  ("zufriedenstellende"),  I 
think  this  term  is  open  to  crititism  when  it  is  borne  in  mind  that  he  con- 
siders hmitation  of  motion  of  from  20  to  90  degrees,  as  well  as  varus 
and  valgus  deformities  with  an  equal  restriction  of  motion,  all  as  being 
satisfactory  results. 

Coenen  advocates  an:esthetization  of  the  patient,  and  the  application 
of  a  plaster-of-Paris  bandage  or  splints  with  the  elbow  at  an  obtuse 
angle,  two  assistants  being  employed  to  correct  the  deformity  while  the 
plaster  hardens,  one  by  extension  on  the  forearm,  the  other  by  counter- 
extension  on  the  humerus  by  means  of  a  sling.  He  treated  a  series  of 
ten  patients  by  this  method,  and  calls  the  results  "nearly  ideal;"  yet 
in  the  series  thus  treated  there  were  two  cases  of  cubitus  varus,  and  one 
in  which  flexion  was  limited    10  degrees. 

Destot,  Vignard,  and  Barlatier  generally  used  plaster  of  Paris,  and 
prefer  it  to  splints.  For  supracondylar  fractures  they  prefer  the  position 
of  acute  flexion;  yet  of  25  supracondylar  fractures  recorded,  a  perfect 
result  was  secured  in  only  11,  and  no  perfect  results  were  obtained  in 
14  cases  of  other  varieties  of  fracture.  What  they  call  "good"  results 
were  secured  in  22  cases  all  told,  including  8  cases  of  supracond\lar 
fracture;    but  among  good  results  thev  include  cases  of  limited  motion. 

Cotton  concludes  that  for  fractures  of  the  external  cond\le  the  best 
position  is  acute  flexion;  for  supracond\  lar  fractures  he  prefers  to  dress 
the  elbow  at  right  angles  on  an  internal  angular  splint,  and  after  two 
weeks  to  extend  the  elbow  to  135  degrees,  to  discover  whether  or  not 
there  is  gunstock  defbrmit\-;  if  there  is,  he  thinks  it  may  still  be  success- 
fully corrected  after  this  lapse  of  time.  He  employed  the  position  of 
acute  flexion  in  only  10  of  his  cases;  and  in  only  one  of  these  (Case  3) 
was  it  known  that  a  perfect  result  had  been  obtained.  As  in  several 
of  these  cases  (Nos.  19,  20,  24)  flexion  was  limited  after  recovery,  and 
as  several  of  his  skiagraphs  show  the  fracture  still  unreduced,  with  the 
elbow  in  acute  flexion,  it  is  evident  that  by  the  term  acute  flexion  he  does 
not  understand  the  same  position  which  is  here  called  hyperflexion; 
since  it  is  practically  impossible  to  put  the  elbow  in  hyperflexion  unless 
the  fracture  has  been  reduced. 

In  the  present  series  of  cases  the  position  of  h\perflexion  was  employed 
routinely,  because  it  is  the  one  position  in  which  (in  the  overwhelming 
majority  of  cases)  the  fragments  are  retained  accurately  in  place  without 
the  aid  of  pads,  splints,  etc.  The  patients  were  all  treated  in  very  busy 
out-services,  and  did  not  receive  a  disproportionate  amount  of  attention; 
but  the  aim  was  to  reduce  the  fractures  at  the  earliest  possible  moment, 
to  ascertain  by  means  of  the  X-rays  that  reduction  was  complete,  to 
maintain  the  fragments  in  accurate  apposition  until  consolidation  occurred, 
and  then  to  leave  the  elbows  alone,  tor  function  to  be  restored  by  active 


RESULTS  97 

movements  by  the  patient  himself.  The  low  percentage  of  cases  in 
which  cubitus  varus  resulted  (H  per  cent.,  compared  with  25,  28,  and  40 
per  cent,  of  other  observers),  clearly  demonstrates  the  fact  that  if  reduc- 
tion is  successfully  accomplished  and  maintained  there  is  no  need  to 
extend  the  forearm  on  the  arm  to  guard  against  the  occurrence  of  this 
deformity. 

But  the  mere  position  of  hyperflexion  is  not  in  itself  a  panacea;  as 
Destot,  Vignard,  and  Barlatier  very  justly  remark  (loc.  cit.,  p.  171): 
"The  attitude  of  the  forearm  is  of  no  consequence  except  as  it  permits 
the  maintenance  of  the  fragments  in  a  more  or  less  good  position.  If 
complete  extension  is  the  only  position  which  permits  the  maintenance 
of  reduction,  one  should  not  hesitate  to  give  this  position  to  the  forearm." 
Nor  do  I  deny  that  it  is  possible  to  maintain  the  fragments  in  place  by 
the  aid  of  splints,  plaster  casts,  weight  extension,  etc.,  in  some  position 
other  than  that  of  hyperflexion;  or  that  good  results  are  not  sometimes 
obtained  by  such  methods  (more  by  good  luck  than  good  management, 
however);  but  what  I  do  believe  is  that  a  position  which  by  anatomical 
factors  mechanically  maintains  the  fragments  in  place  after  reduction 
has  been  secured,  and  the  routine  employment  of  which  produces  the 
satisfactory  results  here  recorded  in  a  fairly  large  series  of  fractures 
usually  (but  I  believe  erroneously)  accorded  a  very  gloomy  prognosis, 
is  one  which  deserves  wider  recognition  than  it  at  present  enjoys. 


Refkrences. 

Allis.     Annals  of  Anat.  and  Surg.  Soc.  of  Brooklyn,  1880,  ii,  289. 
Brewer.     Te.xt-book  of  Surgery,  Philadelphia,  igog,  p.  741. 

Chutro.     Fracturas  de  la  Extremidad  Inferior  del  Hiimero  en  los  Ninos.     Tesis,  Buenos 
Aires,  1904. 

Coenen.      Beitr.  z.  klin.  Chir.,  1908,  Ix,  313. 

Cotton.     Annals  of  Surgery,  1902,  i,  75,  242,  365. 

Da  Costa.     Modern  Surgery,  Philadelphia,  1907,  p.  496. 

Davis,  G.  G.     Trans.  Coll.  Phys.  Phila.,  1898,  xx,  197;  Annals  of  Surgery,  1899,  i,  40. 

Dauvergne.     Bull.  Gen  de  Therap.  Med.  et  Chir.,  1873,  Ixxxv,  11. 

Destot,  Vignard,  et  Barlatier.     Les  Fractures  du  Coude  chez  I'Enfant,  Paris,  1909. 

Eisendrath.     Keen's  Surgery,  Philadelphia,  1907,  ii,  193. 

Eve.     American  Practice  of  Surgery,  edited   by  Bryant  and   Buck,  New  York,  IQ07,  iii, 

139- 

Hilgenreiner.     Beitr.  z.  klin.  Chir.,  1903,  xxxix,  275. 

Jones.     Provincial  Med.  Jour.,  1895,  xiv,  28. 

Judet.     Cited  by  Destot,  Vignard,  et  Barlatier. 

Kocher.     Beitr.  2.  Kenntniss  einiger  praktisch  wichtiger  Fracturformen.     Basel  u.  Leipzig, 
1896 

Lane.     Trans.  Amer.  Surg.  Assoc,  1891,  ix,  393. 

Lusk.     Annals  of  Surgery,  1908,  ii,  432. 


98  FRACTURES  OF  THE  EinOlV 

Moucliet.     Medecin  Praticien,  i6  Fev.,  igog. 

Miiller.     Cited  by  Destot,  Vignard,  et  Barlatier. 

Pilcher.     Internat.  Text-book  of  Surgery,  Philadelphia,  IQDJ,  i,  551. 

Potter.     Jour,  of  Anat.  and  Physiology,  1895,  xxix,  488. 

Roberts.     Trans.  Amer.  Surg.  Assoc,  1891,  ix,  281 ;   1892,  x,  54,  68. 

Scudder.     Treatment  of  Fractures,  Philadelphia,  1907. 

Siter.     Trans.  Phila.  Acad,  of  Surgery,  1905,  vii,  32. 

Smith,  H.  L.     Bost.  Med.  and  Surg.  Jour.,  1894,  cxxxi,  5^6;   1895,  cxxxiii;  i,  14. 

Stewart.     Manual  of  Surgery,  Philadelphia,  1907,  p.  309. 

Stimson.     Trans.  Amer.  Surg.  Assoc,  1891,  ix,  284. 

Thomas,  J.  J.     .Annals  of  Surgery,  1909,  i,  333. 

Tiffany.     Trans.  .'\mer.  Surg.  As.soc,  1892,  x,  283. 

Wharton.     Minor  and  Operative  Surgery,  Philadelphia,  1905,  p.  378. 

Wilms.     Practical  Surgery,  edited  by  v.  Bergmann  and  Bull,  Philadelphia,  1904,  iii,  176. 


CLINICAL    HISTORIES 


SUPRACONDYLAR  FRACTURES. 

I.  Supracondylar  Fracture  of  Right  Humerus. — October  13,  1903. 
Harold  E.,  aged  6  years.  From  tall.  Symptoms  not  recorded.  Skia- 
graph (Fig.  71),  made  October  14,  1903,  shows  internal  and  posterior 
displacement  of  lower  fragment,  and  stripping  up  of  periosteum. 
Treatment  not  recorded.     No  further  notes. 

Result. — Not  traced. 


Fig.  71. — Case  I.      Skiagrapli  of  supracondylar  fracture. 

2.  Supracondylar  Fracture  of  Left  Humerus. —  January  12,  1904.  Katy 
H.,  aged  2  years.  From  fall.  Symptoms:  Crepitus,  mobility;  no  deform- 
ity. Treatment:  Internal  angular  splint,  with  arm  bound  to  side  of  chest. 
Two  weeks  later  developed  measles  and  was  dressed  at  home  thereafter 
by  family  physician.  Full  extension  was  obtained  one  week  after 
removal  of  splint;   parents  did  not  notice  any  loss  of  carrying  angle. 

On  March  21,  1905,  had  another  fall,  injuring  the  same  elbow.     Skia- 


102 


CLINICAL  H/STOR/ES 


graph  (Fig.  72),  made  then,  shows  recent  fracture  just  above  epiphyseal 
hne  (transverse  diaconch  hir  fracture),  and  slight  thickening  above  con- 
dyles, from  previous  supracond\  lar  fracture.  The  patient  was  not  under 
my  care  at  the  time  oi  this  second  injury.  In  the  skiagraph  the  centre 
tor  the  capitellum  of  humerus  is  seen  below  external  condyle,  its  shadow 
overlapping  that  of  upper  end  of  ulna.  Between  capitellum  and  shaft 
ot  humerus  is  a  shell  of  bone  (belonging  to  diaphvsis),  which  has  been 
fractured  by  recent  injury. 


Fig.  72. — Case  2.     Skiagraph  of  old  supracondylar,  recenr  diacond\lar  fracture. 


Result. — Examined  April  28,  1907.  Extension  and  flexion  complete, 
also  supination  and  pronation.  There  is  slight  gunstock  deformit\", 
the  external  condyle  being  prominent  and  displaced  a  little  anteriorly; 
this  makes  the  carrying  angle  about  igo  degrees,  the  forearm  falling 
about  10  degrees  to  the  ulnar  side  of  the  axis  of  the  humerus.  This 
deformity  mav  be  due  to  the  first  fracture,  as  by  the  use  of  an  mternal 
angular  splint  it  is  usually  impossible  to  prevent  inward  rotation  of  the 


SUPRA  CON  DTLAR  FRACTURES 


KKJ 


lower  fragment.  But  as  the  cliild  was  not  examined  until  two  years 
after  the  second  fracture,  it  is  not  impossible  that  the  deformity  should 
be  attributed  to  it. 


Fig.  73. — Case  3.     Skiagraph  of  supracondylar  fr.icture,  on  riglit-angle  splint. 


Fig.  74. — Case  3      After  hyperflexion. 


104 


CLINICAL  HISTORIES 


3.  Supracondylar  Fracture  of  Left  Humerus. — November  27,  1904.  Ella 
McG.,  aged  9  years.  Fall  on  overextended  palm.  Symptoms:  Swelling, 
pain,  tenderness,  crepitus,  and  mobility.  Treatment:  Resident  phy- 
sician applied  an  internal  angular  splint.  Skiagraph  (Fig.  73),  made 
eighteen  hours  later,  showed  lower  fragment  still  posterior,  and  tilted 
upward  by  action  of  triceps,  and  flexed  on  forearm  by  muscles  attached 
to  epitrochlea  and   epicondyle.     At  next  visit,  therefore  (the  third  day 


Fig.  75. — Case  5.     Supracondylar  fracture  after  hyperflexion. 


after  the  injury),  the  elbow  was  hvperflexed,  the  excellent  position 
obtained  being  shown  in  Fig.  74,  from  a  skiagraph  made  on  the  fourth 
day  of  treatment.  In  tliird  week  elbow  was  dressed  at  right  angles, 
and  at  the  end  of  fourth  week  the  forearm  was  carried  in  a  sling  without 
any  dressing. 

Result. — By  the  end  of  sixth  week  flexion  and  extension  were  complete, 
carrying  angle  was  normal,  and  all  functions  were  perfect. 


SUPRACONDrUR  FRACTURES 


105 


4.  Supracondylar  Fracture  of  Left  Humerus. — August  27,  1 904.  Harry 
R.,  aged  3  years.  From  tall.  Svnptonis  not  recorded.  Treatment : 
Hyperflexion. 

Result. — Examined  April  27,  1907.  Full  extension,  obtained  a  few 
days  after  stopping  treatment;  full  flexion;  carrymg  angle  normal. 
Perfect  result. 


Fig.  76. — Case  5.     At  right  angles. 


5.  Supracondylar  Fracture  of  Right  Humerus. — October  30,  1905.  josepb 
T.,  aged  six  years.  From  tall.  Symptoms  not  recorded.  Treatment: 
Dressed  on  internal  angular  splint  by  resident  physician,  on  account  of 
great  swelling.  Next  day  I  dressed  elbow  in  hyperflexion,  in  spite 
of  swelling.  Skiagraph  (Fig.  75),  made  after  this  dressing,  showed  good 
position.  On  November  i,  on  account  of  swelling,  the  resident  again 
dressed  it  on  internal  angular  splint;  he  was  skeptical  of  the  value  of 
the  position  of  hyperflexion  at  an\-  rate.  Patient  did  not  return  until 
November  6;  skiagraph  made  this  day,  with  elbow  still  on  internal 
angular  splint,  showed  customary  deformity  of  recent  fracture  (Fig.  76). 


106 


CLINICAL  HISTORIES 


November  S,  1  again  set  the  fracture,  keeping  fragments  in  position  by 
the  position  of  hyperflexion.  Fig.  77,  from  skiagraph  made  November 
9,  shows  very  satisf'actorv  position  obtained.  This  fracture  was  not 
again  dressed  by  the  resident. 


Jig.  77. — Case  5.     Again  in  hvperflexion. 


Result. — Examined  December  29,  1905.  Full  flexion,  and  extension 
to  170  degrees  (practicalh'  complete);  carr\ing  angle  normal.  It  has 
been  impossible  to  trace  this  patient  longer  than  for  two  months  after 
his  injury;  almost  certainly  he  now  has  absolutely  complete  extension, 
and  the  result  may  be  considered  perfect. 

6.  Supracondylar  Fracture  of  Left  Humerus. — November  10,  1905.  Marie 
F.,  aged  two  years.  From  fall.  Symptoms :  No  deformitv,  but  crepitus 
and  mobdit}'.  Skiagraph  (Fig.  78),  made  same  da\',  is  ver\'  indistinct, 
but  shows  posterior  displacement  of  lower  fragment.  Treatment:  After 
ascertaining  result  of  skiagraph,  elbow  was  dressed  in  hvperflexion. 

Result. — This  patient  cannot  be  traced. 


SUPRICONDYLIR  FIUCTURES 


107 


Fig.  78. — Case  6.     Skiagraph  of  supracondylar  fracture. 


Fig.  79. — Case  7.     Skiagraph  ot  supracondylar  fracture 


108 


CLINICAL  HISTORIES 


7.  Supracondylar  Fracture  of  Left  Humerus. — November  12,  1905. 
Stanley  H.,  aged  fourteen  months.  From  fall.  Symptoms :  Crepitus, 
mobility  back  and  forth  above  cond\les.  Treatment :  Hyperflexion. 
Skiagraph  (Fig.  79),  made  after  setting  fracture,  shows  perfect  reduc- 
tion, line  of  fracture  passing  across  humerus  about  half  an  inch  above 
epiphyseal  line. 

Result. — Examined  December  19,  1905.  Full  flexion  and  extension, 
carrying  angle  normal.     Perfect  result. 


Fig.  80. — Case  8.   Skiagraph  of  comminuted  supracondylar  fracture. 


8.  Comminuted  Supracondylar  Fracture  of  Left  Humerus. — December 
19,  1905.  Benny  G.,  aged  eight  years.  Pushed  down  by  another  boy, 
falling  on  outer  side  of  elbow  and  forearm.  Symptoms :  Considerable 
localized  swelling  below  internal  cond\le;  joint  very  mobile,  almost 
flail-like;  crepitus;  loose  fragment,  easily  movable  beneath  skin,  above 
internal  cond\le.  Treatment :  Etherized;  motion  very  free,  including 
adduction  and  abduction  of  elbow;  fragments  manipulated  into  position 
by  direct  pressure  and  b\'  alternate  flexion  and  extension  of  elbow. 
Dressed  in  hyperflexion.  Skiagraph  (Fig.  80),  made  next  day,  shows 
various  fragments  in  good  position.  December  22,  first  dressing;  no 
pain  since  first  night.  January  ig,  full  flexion  and  almost  complete 
extension;  carrying  angle  normal. 


SUFRACONDTLAR  FRACTURES 


]()() 


Result. — June  8,  1907.  Saw  mother,  who  savs  there  is  full  flexion 
and  full  extension,  and  that  elbow  is  normal  in  every  way.  Perfect 
result. 

9.  Supracondylar  Fracture  of  Left  Humerus. —  July  12,  1906.  Joseph  B., 
aged  seven  years.  Made  mis-step  on  stairs,  caught  left  arm  in  bannis- 
ters. Symptoms:  Great  localized  swelling  and  tenderness;  no  crepitus, 
no  mobility.  Skiagraph  (mislaid)  shows  partial  supracondylar  fracture 
from  above  internal  cond}'le  half-way  across  shaft  toward  external  condyle. 
Treatment:    Hyperflexion.     August  8,  in  sling.     August  14,  out  of  sling. 

Result. — Examined  August  28,  1906.  Extension  complete,  flexion 
complete;   carr\ing  angle  normal.     Perfect  result. 


1^  Fig.  81. — Case  10.    Photograph  showing  full  flexion  after  recovery  from  supracondylar 

^  fracture. 

10.  Supracondylar  Fracture  of  Left  Humerus. —  July  16,  1906.  Josephine 
K.,  aged  four  years  and  a  halt.  From  fall  on  street;  it  is  not  known 
how  she  landed.  Symptoms:  Marked  mobility,  crepitus,  posterior  dis- 
placement of  lower  fragment.  Treatment:  Hyperflexion.  August  20,  in 
sling.     September  20,  discharged. 

Result. — Examined  August  22,  1907.  All  functions  normal.  Right 
elbow  (never  injured),  flexion,  25  degrees;  extension,  187  degrees;  carrying 
angle,  165  degrees. 

Left  elbow  (fractured),  flexion,  30  degrees;  extension,  192  degrees; 
carrying  angle,    167  degrees. 

Figs.  81  and  82,  from  photographs  made  this  da\-,  show  the  result. 


no 


CLINICAL  HISTORIES 


II.  Supracondylar  Fracture  of  Left  Humerus. — September  ii,  1906. 
Frank  F.,  aged  eleven  years,  llirown  down  in  a  fight,  landing  on  ante- 
rior, surface  of  extended  forearm,  and  suddenly  hypere-xtending  elbow. 
Taken  to  near-by  physician,  who  dressed  elbow  on  internal  angular 
splint.  Came  under  my  care  next  day.  Symptoms:  Pain,  swelling, 
tenderness,  crepitus,  and  mobility;  no  injury  to  nerves  noted.  Diag- 
nosis: Supracond}lar  fracture.  Treatment:  By  extension  and  counter- 
extension,  and  by  hyperextension  of  elbow,  lower  fragment  was  unlocked 
from  shaft,  and  then  In  sudden  and  forcible  flexion  elbow  was  brought 
into  hyperflcxcd  position,  and  thus  dressed.     Skiagraph  (Fig.  S3),  made 


Fig.  8a. — Case  10.   Photograph  showing  lull  extension  after  recovery  from  supracondylar 

fracture. 


September  Z2,  shows  fracture  ver\  nearh'  reduced.  At  the  next  dressing 
an  effort  was  made  to  draw  the  lower  fragment  still  farther  forward. 
October  19,  in  sling.  October  23,  out  of  sling.  November  15,  extension 
to  100  degrees  only.  November  22,  extension  to  120  degrees.  November 
28,  extension  to  150  degrees.  December  3,  the  same.  January  3,  1907, 
the  bo\'  now  returns  complaining  of  tenderness  (not  pain)  along  course 
of  median  nerve.  This  he  says  has  existed  for  some  weeks.  Toda\' 
the  nails  fell  off  the  index  and  middle  finders;  these  fingers  are  numb, 
and  evidently  the  seat  of  trophic  changes.  Skiagraph  (Fig.  84),  made 
today,  shows  periosteum  stripped  off  posterior  surface  of  humerus  for 
several  inches,  with  callus  formed  on  under  surface  of  periosteum;  this 
mass  of  callus  seems  to  prevent  full  extension  of  elbow,  as  olecranon 


SUPRA  CON  n  VLIR  FRACTURES 


\U 


impinges  upon  if.       The   lower  end  ot   tin-  upper  fragment  is   pronnnent 
anteriorh  ;   jierhaps  tiie  median  nerve  is  stretched  over  it.       The  patient's 


Fig.  83. — Case  11.    Skiagraph  of  supracondylar  fracture,  September  22,  1906. 


Fig.  84. — Case   II.    Skiagraph  of  supracondylar  fracture,  January  3,   1907. 


112 


CLINICAL  HISTORIES 


elbow  was  put  on  an  internal  angular  splint,  in  the  hope  that  complete 
rest  might  allow  the  neuritis  to  subside.  A  photograph  (Fig.  85)  made 
January  31,  shows  the  dystrophic  nails  very  well.  As  no  improvement 
occurred  under  conservative  measures,  it  was  determined  to  resort  to 
operation  to  relieve  the  neuritis.  Accordingly,  on  April  2,  1907,  over 
si.x  months  after  the  injur} ,  the  median  nerve  was  e.xposed  in  front  of  the 
elbow-joint;  it  was  found  stretched  over  the  prominent  lower  end  of 
the  upper  fragment,  shown  in  Fig.  84.  The  nerve  was  released  from 
its  adhesions,  and  the  prominent  bone  chiselled  off;  layers  of  fascia  were 


Fig.  85. — Case  11.  Photograph 
showing  trophic  changes  in  finger 
nails  as  a  result  of  neuritis  of  median 
nerve.     January  31,  1907. 


Fig.  86. — Case  11.  Photograph  made  eight 
weeks  after  operation,  to  show  improvement  in 
finger  nails.     May  28,  1907. 


carefully  sutured  together  beneath  and  above  the  nerve,  and  the  incision 
was  closed.'  April  16,  no  tenderness  along  the  course  of  median  nerve 
remains;  the  nails  are  growing  again.  May  28,  the  accompan\ing  pho- 
tograph (Fig.  86)  was  made,  eight  weeks  after  operation,  to  show 
improvement  in  nails.  The  elbow  can  now  be  e.xtended  to  150  degrees, 
and  flexed  to  40  degrees.  The  boy  has  no  pain,  but  his  finger  tips  are 
still  tender  on  deep  pressure,  as  is  also  the  course  of  the  median  nerve  in 
the  forearm.  July  23,  extension  to  160  degrees.  September  10,  extension 
to  180  deo-rees. 


'  Operation  by  Dr.  G.  G.  Davis,  at  the  Orthopaedic  Hospital. 


SUPR.ICONOrL.lR  FR  ICTURES  IV-i 

Result. — Examined  November  5,  1907.  I'ull  flexion  and  full  exten- 
sion; carrying  angle,  165  degrees  (normal  elbow,  170  degrees).  Figs. 
87  and  88  show  the  result. 


Fig.  87. — Case  11.   Photograph   showiiif^  full   Htxion    after  supracondylar  fracture  of   left 

humerus. 


Fig.  88. — Case  11.    Photograph   showing   full   extension   after   supra cond\lar   fracture   of 

left  humerus. 

12.   Supracondylar     Fracture     of     Left     Humerus. — October     25,     iqo6. 
George  W.  C,  aged  six  \ears.     Thrown   in  fight,  landing  on   extensor 
surface  ot  left  forearm,  which  was  in  flexion.     Svinpioins:  Lower  frag- 
ment  posterior.      Treatment:   Hvperflexion.     Skiagraph  (Fig.  89)   made 
8 


114 


CLINICAI.  HISTORIES 


October  29,  shows  good  position.  November  15,  in  sling.  November 
28,  extension  to   160  degrees. 

Result. — Examined  April  11,  1907.  Full  flexion,  full  extension; 
carrying  angle  normal.      Perfect  result. 

13.  Supracondylar  Fracture  of  Right  Humerus. — September  14,  1906. 
Marie  B.,  aged  three  \ears.  Fall.  Svmptonis:  Not  recorded.  Dressed 
by  resident  physician  at  right  angle.  Skiagraph  (Fig.  90)  shows  fracture 
still  unreduced.  Treatiunit:  Elbow  put  into  position  of  hyperflexion. 
September   16,  1906;  at  end  of  four  weeks  in   sling. 

Result. — Father  reports,  April  28,  1907,  that  elbow  can  be  fully 
extended  and  tulK'  flexed;  carr\  ing  angle  normal.     Perfect  result. 


Fig.  8g. — Case  12.   Skiagraph  of  supracondylar  fracture,  m  hyperflexion. 


14.  Supracondylar  Fracture  of  Right  Humerus. — November  17,  1906. 
Emma  D.,  aged  fi\e  years.  From  fall  on  o\erextended  palm.  Dressed 
by  interne  in  Velpeau  position.  Examined  b\  me  November  19. 
Sytnptoius:  Considerable  swelling,  lower  fragment  slides  treeh'  antero- 
posteriorh',  producing  crepitus  as  forearm  is  moved  tore  and  aft. 
Treatment:  Hyperflexion.  Skiagraph  (Fig.  91),  made  with  elbow  in 
hyperflexion,  shows  good  position  of  fragments.  December  12,  in  sling. 
December  17,  out  of  sling.  December  27,  has  fallen  and  bruised  same 
elbow  again;  painful,  and  is  held  stiff.  Ichthvol  ointment  applied. 
January  J,  1907,  has  been  in  a  trollev  accident,  and  has  hurt  same  elbow 
third   time.     Motion   is   limited   to  a  range  of  30  degrees,  and   rotation 


SU PR/ICON DTLIR  IR  ICTURI-.S 


115 


Fig.  90. — Case  16.    Skiagraph  of  supracondylar   fracture  before   reduction. 


Fig.  91. — Case  14.  Skiagraph  of  supracond)  hir  fracture  in  h}perfle.\ion. 


]1() 


CLINICAL  HISTORIES 


of  forearm  is  poor.  Dressed  on  internal  angular  splint,  with  ichthyol 
ointment.  Fehriiar\'  14,  flexion  to  75  degrees,  extension  to  no  degrees; 
no  pain. 

Result. —  This   patient  cannot   be  traced. 

15.  Supracondylar  Fracture  of  Right  Humerus. — December  15,  1906. 
Joseph  M.,  aged  four  years.  Fell  out  of  express  wagon  yesterday  even- 
ing; probably  landed  on  elbow.  Symptoms:  Forearm  in  full  pronation; 
elbow  held  in  165  degrees  extension;  active  motion  )///,  but  whole  extrem- 
ity is  moved  at  shoulder;    fingers  also  acti\el\'  mo\ed.     Carrying  angle 


Fig.  92. — Case  15.  Skiagraph  of  supracondvlar  fracture  in  hyperflexion. 


preserved;  passive  rotation  of  forearm  normal.  Marked  swelling  over 
internal  condyle,  discoloration  over  external  condyle.  Fold  of  elbow 
looks  and  feels  prominent.  Tender  over  lower  humerus,  especially 
in  fold  of  elbow.  Relation  of  cond\les  to  olecranon  preserved.  In- 
distinct soft  crepitus  on  flexion  and  extension;  no  eMdent  abnormal 
mobility.  Diagnosis  was  separation  of  lower  epiph\sis,  but  skiagraph 
(Fig.  92),  made  December  17,  shows  line  of  fracture  transverse  above 
condyles;  centre  for  capitellum  seen  below  epiph\seal  line.  The  skia- 
graph, however,  does  not  exclude  additional  injury  to  cartilaginous  end 


SUPRA  CON  PrLJR  FRACTURES 


117 


Full  flexion  and  extension;    car- 


of  luimeriis.  Tiratmcut:  Reducecl  hv  traction,  hyperextension,  and  acute 
flexion;  dressed  in  liyperflexion.  Excellent  position  secured  is  shown  in 
Fig.  92,  from  skiagraph  made  after  dressing  was  applied.  January  10, 
in  sling. 

Result. — Examined  April   13,   1907. 
r}ing  angle  normal;    all  functions  |Hitect.      I'ertect  result. 

16.  Supracondylar  Fracture  of  Right  Humerus. — December  25,  1906. 
Ida  D.,  aged  twenty  months.  Fell  off  chair  yesterday.  Symptoms-: 
Much  swelling  and  ecchymosis.  Dressed  by  resident  physician  in  flexed 
position.  Skiagraph  (Fig.  90),  made  December  26,  shows  fragment  still 
slightly  posterior;  centre  for  capitellum  can  be  detected  in  clear  car- 
tilaginous area  between  humerus  and  ulna.  Treatment:  Fracture 
re-set,  December  27,  b\'  traction,  h\perextension,  and  acute  flexion; 
dressed  in  hyperflexion. 

Result. — Patient  never  returnetl  for  treatment,  and  cannot  be  traced. 


Fig.  Q3. — Case  l8.   Photograph  sliowing  full  fiexion  after  recover)-  from  supracondylar 

fracture. 


17.  Supracondylar  Fracture  of  Right  Humerus. — February  19,  1907. 
Sarah  W.,  aged  two  \ears.  Svmploms:  Localized  pain,  tenderness,  and 
swelling;  slight  crepitus  obtained  by  holding  shaft  of  humerus  in  one 
hand  and  rotating;  lower  fragment  on  it  throuch  medium  ot  forearm;  no 
antero-posterior  mobility.  Treatment:  H\perflexion.  Skiagraph,  made 
today,  very  indistinct.  February  28,  extended  b}'  force  to  180  degrees, 
to  assure  normal  carrying  angle.  March  18,  in  sling,  active  extension  to 
160  degrees. 

Result. — Examined  March  25,  1907.  Full  flexion  and  extension;  carry- 
ing angle  normal.     Perfect  result. 


118 


CLINICAL  HISTORIES 


l8.   Supracondylar    Fracture   of    Left   Humerus.      April    14,    1^07.      Katy 
S.,    aged    four  \ears.      Fell    on   extensor  surface  of    forearm,   which   was 


Fig.  94. — Case  18.  Skiagrapli  of  .supraconcI\Iar  fracture  in  lixperflexion. 


Fig.  95. — Case  18.   Pliotograpli  showing  full  extension  after  recovery  from  supracondylar 

fracture. 


SUPRACOMD )  L.IR  FR.ICTURES 


119 


flexed  to  right  angle.  Dressed  by  resident  physician  in  Velpeau  position. 
Symptovis  (April  15):  Some  swelling,  no  displacement,  no  mobility, 
crepitus  uncertain.  Full  flexion  and  extension  possible,  if  forced. 
Treatment:  Hyperflexion.  Skiagraph  (Fig.  94),  made  April  16,  shows 
fracture  transversely  at  base  of  condyles,  fragment  in  good  position; 
the  periosteum  has  been  stripped  up  ott"  posterior  surface  of  humerus 
for  an  inch  or  so. 

;?fJ.«/^— Examined    March    28,    190Q.      Full    flexion,    full    extension; 
carrying  angle  normal.      Perfect  result  (Figs.  9^  and  95). 


Fig.  96. — Case  19.  Skiagraph  of  supracondjlar  fracture,  antero-posterior  view. 


19.  Supracondylar  Fracture  of  Left  Humerus. —  July  16,  1907.  John  S., 
aged  eight  years.  Fell  last  evening  on  overextended  hand,  elbow  being 
in  nearly  full  extension.  Famil)  ph)sician  applied  ointment,  bandaging 
the  elbow  in  nearly  full  extension.  Seen  b\-  me  toda\-.  Symptoms: 
Elbow  in  almost  full  extension,  carrying  angle  lost,  external  condyle 
down  and  posterior,  olecranon  and  internal  condyle  displaced  posteriorly 
and  to  inner  side.  Skiagraph,  made  today,  shows,  in  lateral  view, 
irregular  and  jagged  fracture  above  the  cond\  les,  the  epiph\  seal  line 
and  capitellum  being  normal.  Fig.  96,  the  antero-posterior  \iew,  is 
considerabl\-  obscured  b\'  the  ointment  and  bandages,  but  shows  an 
irregular  fracture  above   the  condyles,   the  external  condyle  being  di.s- 


120  CLINICAL  //ISTORfES 

placed  downward,  causing  cubitus  varus.     Trrntinent:  Considerable  force 
had    to   1h'  used  in  reduction,  causing  crepitus,  audible  to  bv-standers; 


Fig.  97. — Case  20.   I'liotograph  showing  full  flexion  after  recovery  from  supracondylar 

fracture. 


i-  s 


Fig.  98. — Case  20.   Photograph  showing  full  extension  after  recovery  from  supracondylar 

fracture. 

dressed  in  Inperflexion.     September  5,  tanuh  ph\  sician,  who  has  treated 
patient  since  fracture  was  set,  reports  extensujn  to  135  degrees. 


SUPRACONDVI.IR  FR.ICTl'RES  121 

Result. — Family    physician    reports,    October    I,    1907,    that  there    is 

complete    flexion    and    extension,    and    that    carrying    angle    is  normal. 
Perfect  result. 


I'IG.  99. — Case  21.   Photograph  showing  full  flexion  after  recovery  from  supracondylar 

fracture. 


Fig.   100. — Case  21.   Photograph  showing  full  extension  after  recoverv  fiom  supracondylar 

fracture. 


122  CLINIC.IL  IIIS'lOR/ES 

20.  Supracondylar  Fracture  of  Left  Humerus. —  |anuar\'  25,  1908.  F'dith 
S.,  aged  six  years.  Fell  todav  on  extensor  surface  of  forearm,  elbow- 
being  flexed  to  right  angle.  Dressed  by  resident  physician  on  anterior 
angular  splint.  Skiagraph,  which  uiifortimateh  has  been  lost,  made 
January  27,  shows  lf)wer  fragment  still  unreduced.  Treatvient:  Dressed 
in  hyperflexion;  skiagraph  made  with  elbow  thus  showed  fragment  still 
posterior.  January  28,  etherized  and  reduction  attempted  by  forcible 
hyperextension,  traction,  and  again  h\  perflexion.  Skiagraph  made 
after  this  attempt  shows  improvement,  but  still  not  absolutely  complete 
reduction.  It  is  most  unfortunate  that  these  skiagraphs  have  all  been 
mislaid,  owing  to  building  changes  in  the  hospital.  February  i,  dressed; 
swelling  much  less;  no  pain  since  last  note.  Februar\'  20,  in  sling. 
March  17,  out  of  sling  for  three  weeks;  extension  to  135  degrees. 
March  24,  extension   to    140  degrees. 

Result. — Examined  March  11.  igog.  Extension  to  180  degrees, 
flexion  to  35  degrees;  carrying  angle  normal.  (Other  elbow  has  exten- 
sion to  185  degrees,  flexion  to  32  degrees.)  Perfect  result,  shown  in 
Figs.  97  and  98,  from  jihotographs  made  toda\-. 

21.  Supracondylar  Fracture  of  Left  Humerus. — September  27,  1908. 
Martm  N.,  aged  two  \  ears.  Fell  out  of  bed,  landing  on  extensor  surface 
of  elbow,  which  was  flexed  to  a  right  angle.  Symptoms:  Much  swelling, 
elbow  held  in  nearly  full  extension,  forearm  in  slight  pronation;  black 
and  blue  on  extensor  surface  of  upper  part  of  ulna  (slight  haematoma .''), 
confirming  mother's  account  of  manner  in  which  injury  was  received; 
moderate  gunstock  deformit\'.  which  can  be  markedly  increased  (to  about 
210  degrees);  cubitus  valgus  is  also  easily  produced.  Crepitus  and 
point  of  false  motion  above  condyles,  which  can  be  freely  moved  back 
and  forth  with  forearm,  while  humerus  is  held  still  with  other  hand. 
Treatmetit:  Reduced  b\-  h\  perextension,  traction,  and  h\perflexion. 

Result. — Examined  |ul\  12,  1909.  Full  extension  and  full  flexion; 
although  the  supinator  region  looks  a  little  prominent  in  full  extension, 
the  carr\'ing  angle  is  found,  on  measurement  with  the  goniometer,  to 
be  the  same  as  that  of  normal  elbow  (175  degrees).  Perfect  result 
(Figs.  99  and  100). 


TRANSVERSE  DIACONDYLAR  FRACTURES. 

22.  Transverse  Diacondylar  Fracture  of  Left  Humerus. — October  1 1,  1905. 
Josephine  T.,  aged  three  years.  From  fall.  Symptoms  not  recorded. 
Skiagraph  (Fig.  loi),  made  next  day,  shows  irregular  line  of  fracture, 
transverseh'  through  cond\les,  with  slight  displacement  of  capitellum 
and  lower  fragment  posteriorly.  Treatment:  Hyperflexion  for  four 
weeks. 


DIACONnri.lR  IRACTURES 


123 


Result. — Exaniiiucl   December  22,  1905.      Full   flexion  :inc!  full  exten- 
sion; carr\ing  angle  noriiKil.      Perfect  result. 


Fig.   IOI. — Case  22.   Skiaj^ranli  of  tliaLonil\  lar  fracture  hetore  reduction. 


Fig.  102. — Case  23.  Skiagraph  of  diacondylar  fracture  in  hyperflexion. 


124 


CLIN  I  C.I  L  // /STORIES 


23.  Transverse  Diacondylar  Fracture  (Comminuted)  of  Right  Humerus.- — 
November  19,  1905.  Joseph  B.,  aged  thirteen  \ears.  Fell  on  upper 
part  of  flexed  forearm.  Sviiiptoiiis:  Mobility  and  crepitus,  with  outward 
displacement  of  external  condyle.  Skiagraph  (Fig.  102),  made  next  day,, 
showed  comminuted  fracture,  running  more  or  less  transversely  through 
condyles.  Treatment:  Hvperflexion;  in  sling  on  December  19;  dis- 
charged December  29,  1905,  with  extension  to  115  degrees  and  no 
deformity. 

Result. — June  8,  1907,  brother  reports  extension  to  165  degrees,  full 
flexion;  all  functions  normal;  carrying  angle  normal;  no  disabilit)'. 


Fig.  103. — Case  24.  Skiagraph  of  diacondylar  fracture  "by  flexion,"  November  20,  1906. 

24.  Transverse  Diacondylar  Fracture  "by  Flexion"  of  Left  Humerus. — 
November  18,  1906.  Gertrude  O'B.,  aged  three  years.  Fell  ofi^  a  table; 
mother  found  "bonv  lump"  projecting  in  region  of  external  cond\le. 
resident  physician  diagnosticated  fracture  of  neck  of  radius;  there  was 
very  great  swelling,  all  up  to  shoulder;  he  dressed  injur;-  b\  long  palmar 
and  short  dorsal  splint  to  forearm,  which  was  partialh'  supinated.  Seen 
by  me  next  daw  November  19;  swelling  worse;  any  accurate  diagnosis 
impossible,  but  it  was  determined  that  injury  was  confined  to  humerus 


Dl. -ICON D}  L.I li  IR.lCTURhS 


125 


and  involved  elbow-joint.  Treatment:  Anterior  angular  and  short  dorsal 
splint.  Skiagraph  (Fig.  103),  made  November  20,  shows  diacon(l\lar 
fracture  of  humerus,  with  displacement  ot  lower  fragment  anteriorly  and 
inward;  the  arm  is  on  an  anterior  angular  splint,  the  nails  of  which 
are  seen  on  flexor  surface  of  elbow;  owing  to  great  swelling,  it  was  im- 
possible to  flex  elbow  any  more  at  this  time.  The  elbow  (left)  is  viewed 
■obliquely  from  within  and  behind.  The  line  of  fracture  passes  through 
the  condyles,  more  or  less  transversely,  involving  the  diaphysis  a  short 
distance  above  the  epiphyseal  line,  which  latter  is  seen  separating  the 
fragment  of  diaphysis  from  the  centre  for  capitellum.  At  this  age  this 
is  the  only  centre  visible.     A  skiagraph  (Fig.  104),  made  November  22, 


Fig.   104. — Case  24.   Skiagraph  of  diaconylar  fracture  "by  flexion,"  November  22,  IC)06. 


gives  an  antero-posterior  view  of  the  left  elbow,  viewed  from  behind,  in 
full  extension;  this  shows  the  inward  displacement  of  the  lower  fragment, 
carrying  the  forearm  with  it  into  a  marked  gunstock  deformity  {cubitus 
'Varus).  The  centre  for  the  capitellum  retains  its  normal  position  in 
relation  to  the  head  of  the  radius;  the  centre  for  the  head  of  the  radius 
is  not  yet  visible.  The  bon\'  lump  felt  by  the  mother  was  evidenth'  the 
diaphysis  just  above  the  seat  of  fracture.  Having  now  determined 
accurately  the  nature  of  the  fracture,  the  child  was  etherized  on  Novem- 
ber 2^,  the  fifth  day  after  the  injury,  and  an  attempt  was  made  to  reduce 
the  fragment  to  its  normal  place;  by  hyperextension,  direct  pressure 
on  the  lower  fragment,  and  then  by  hyperfiexion,  reduction  was  appar- 
ently  obtained.     The   elbow   was   dressed    in    hyperfiexion.     From    the 


126  CLINICAL  mSJUR/hS 

skiagraph  (Fig.  105),  made  November  30,  one  week  later,  it  is  seen  that 
some  axial  rotation  of  the  lower  fragment  persisted;  and  it  was  thought 
that  extension  probably  would  be  limited  to  about  160  degrees.  Decem- 
ber II,  in  sling.  December  18,  extension  to  135  degrees;  sVight  lubitiis 
varus. 

Result. — F^xaniined  Februar\  lO,  lyoy.  Flexitjn  and  extension  com- 
plete; normal  rotation  of  forearm;  slight  loss  of  carr\ing  angle,  as  shown 
in  Fig.  106,  from  photograph  made  April  15,  1907.  Excellent  result, 
considering  nature  of  mjury. 


Fig.   105. — Case  24.  Skiagraph  of  diacondylar  fracture  by  "flexion"  after  reduction, 

November  30.  1906. 

25.  Transverse  Diacondylar  Fracture  of  Left  Humerus. — March  2,  1907. 
Elwood  H.,  aged  five  years.  Fell  down  stairs.  Symptoms:  Crepitus 
and  mobility.  Treatment:  H\perflexion.  Skiagraph  (Fig.  107),  made 
March  4,  1907,  shows  line  of  fracture  running  transversely  through 
condyles,  just  above  epiphyseal  line.     March  28,  in  sling. 

Result. — Examined  April  10,  1907.  Full  flexion  and  extension; 
carryino;  angle  normal.     Perfect  result. 

26.  Transverse  Diacondylar  Fracture  of  Right  Humerus. — March  29,  1907. 
William  C,  aged  four  years.  Fell  3  feet  off  porch,  probabh'  striking 
on  point  of  elbow.  Resident  physician  diagnosticated  "  intercond}Ioid 
fracture,"  and  dressed  elbow  in  Velpeau  position.     Seen  by  me  March 


DIACONDri.lR  FRJCTURES 


127 


Fig.   io6. — Case  24.   Photograph  showing  end  result  of  diacondylar  fracture  "by  flexion; 
full  extension  and  very  slight  ciihttus  varus,  April  15,  1907. 


Fig.   107. — Case  25.   Skiagraph  of  diacondylar  fracture  in  hyperflexion,  March  4,  1907. 


12,S 


CLINICAL  HISTORIES 


30;  restless  all  night;  elbow  much  swollen,  not  broadened  lateralh",  as  in 
true  intercondylar  fracture;  no  crepitus  obtained.  Diagnosis,  probably 
diacondylar  fracture.  Treatment:  Hyperflexion.  Skiagraph  (Fig.  108), 
made  April  2,  1907,  confirms  last  diagnosis,  showing  line  of  fracture 
transversely  through  condyles,  about  three-eighths  of  an  inch  above 
epiphyseal  line.  The  view  is  of  the  right  elbow,  seen  from  inner  side 
and  behind.      Just  below  shaft  ot   liumerus  is  seen  centre  for  canitellum, 


Fig.   108. — Case  26.  Skiagraph  of  ciiacond}lar  frncturt-  in  hyperflexion,  April  2,  1907 


in  line  with  shaft  of  radius;  this  is  the  onlv  centre  visible.  March  25, 
in  sling.     March  29,  out  of  sling,  extension  to  115  degrees. 

Ri'siilt. — Examined  March  23,  igo8.  Full  extension  and  flexion; 
carrying  angle  normal.  Perfect  result.  It  was  tour  months  after  last 
note  before  full  extension  was  obtained. 

27.  Transverse  Diacondylar  Fracture  of  Rigfit  Humerus. —  ]u\v  12,  1907. 
Robert  N.,  aged   twelve  years.     On  July  7  fell  from   railroad   bumper 


Dfico.xn )  /..Ik  iR  ic.ruRES 


129 


to  ground,  a  distance  of  tour  teet,  landing  on  extensor  surface  of  flexed 
elbow.  Treated  as  a  recent  accident  elsewhere,  bemg  told  his  elbow 
was  "out  of  joint;"  was  dressed  on  anterior  splint,  with  Stromeyer 
screw  at  elbow.  Sviuptoms:  July  I2,  considerable  swelling,  ecchymosis, 
and  blistering;  same  dressing  reapplied,  julv  i6,  on  holding  humerus 
with  one  hand  in  middle  of  shaft,  and  rotating  it  with  other  through 
medium  of  flexed  forearm,  there  seems  to  be  a  point  of  false  motion 
near  cond\  les  of  humerus,  where  also  there  is  great  pain  and  marked 
localized  tenderness  to  pressure.  Slight  flexion  and  extension  of  elbow 
produces  no  pain.  Dressed  in  hyperflexion.  July  i8,  not  re-dressed, 
no  pain.  July  23,  no  pain  on  extension  almost  to  right  angle;  no  tender- 
ness over  cond\'les  or  lower  h.umerus,  nor  on  rotation  of  humerus.  Diag- 
nosis of  fracture  again  uncertain;  but  in  \iew  of  nature  of  iniur\,  which 
almost  certainh'  could  not  have  caused  dishjcation,  and  which  was  t\  jiical 
for  diacondylar  fracture,  and  in  view  of  false  motion  and  other  s\  mptoms, 
I  concluded  to  diagnosticate  this  as  fracture.  Unfortunately,  the  hospital 
where  the  patient  was  treated  has  no  X-ray  plant,  so  the  diagnosis  could 
not  be  confirmed.  Again  dressed  in  acute  flexion.  Jul}'  30,  in  sling 
at  right  angle. 

RcsiiU. — Father  reports,  August  15,  iqoq,  full  flexion  and  full  extension; 
carrying  angle  normal.      Perfect  result. 


Fig.  109. — Case  28.   I'liotograph  of  iiiac(iiid\  hir  fracnirt-  of  the  t)pe  "Posadas"  before 

reduction. 

28.  Transverse  Diacondylar  Fracture  (Type  "Posadas")  of  Right  Humerus. 
— December  30,  1906.  Louis  M.,  aged  ten  \ears.  Fell  off  ash  cart,  land- 
ing on  overextended  hand;  elbow  was  thus  h\perextended,  producing 
a  posterior  dislocation.  Two  photographs  were  made  before  reducing 
the  supposed  dislocation  (Figs.  109  and  no).  Reduction  was  attempted 
9 


130 


CLINIC! I,  HISTORIES 


bv  the  resident  ph\  sician,  without  an  anaesthetic,  by  flexing  the  elbow 
over  the  knee  placed  in  bend  of  elbow.  He  then  dressed  the  elbow  on 
an  internal  anaujar  splint.     The  patient  was  first  seen  b\-  ine  the  next 


Fig.   ho. — Case  i!S.   .^nutlRi  wtw  of  .s.miL-  elbow  before  reduction. 


Fig.   III. — Case  28.  Skiagraph  of  diacondylar  fracture  of  type  "Posadas,"  after  attempt 
to  reduce  dislocation,  January  3,  1907. 


DIACOND )  LAR  FRACTURES 


i;ii 


day,  bur  examination  was  unsatisfactory  on  account  ot  the  swelling. 
The  arm  was  placed  on  an  anterior  angular  splint,  as  the  dislocation 
did  not  seem  to  be  entireh  reduced;  the  possibilit\-  of  fracture  coidd  not 
be  excluded.  Skiagraph  (Pig.  in),  made  fanuar\-  ^,  1907,  shows  that 
there  is  still  subluxation  of  bones  of  forearm  backward,  and  that  there  is 
also  a  fracture  through  the  condyles,  with  forward  displacement  ot  the 
lower    fragment    of   the    hinnerus,    constituting   the    t\pe    described    by 


Fig.   112. — Case  28.  Skiagraph  of  diacondylar  fracture  of  type  "Posadas"  in  li\perHexioii, 
dislocation  and  fracture  both  reduced,   fanuary  18,  1907. 


Prof.  Posadas  (p.  42).  Trcatnwnt:  Toda\,  after  seeing  the  skiagraph, 
I  first  made  very  forcible  extension  and  counterextension,  with  the  elbow 
at  first  fully  extended  and  then  flexed  to  a  ri«ht  angle,  hopino-  thus  to 

o  o  I  o 

overcome  the  subluxation;  and  then,  with  the  elbow  acuteh'  flexed, 
I  rammed  the  forearm  backward  and  downward,  so  as  to  dri\e  the  lower 
fragment  back  into  place.  (No  an:esthetic.)  The  result  is  shown  in 
Fig.   112.  from  a  skiagraph  made  fifteen  da\  s  later  (  yanuar\-  18,  1907); 


132 


CLINICAL  f/ISTORlLS 


the  suliluxiition  is  reduced,  and  the  fragment  has  resumed  its  normal 
relation  with  the  shaft.  In  Fig.  iii  the  small  fragment  lying  between 
the  olecranon  and  the  capitellum  evidently  is  the  separated  epitrochlea. 
Compare  Cases  42  and  44,  where  the  epitrochlea  bears  the  same  relation 
to  the  ulna,  but  where,  owing  to  the  more  advanced  age  of  the  patients, 
the  shadow  ot  the  centre  for  the  trochlea  can  be  seen  also.  January  7, 
less  pain;  this  is  mostlv  confined  to  ring  and  little  fingers.  January  10, 
swelling  less,  not  tender  around  ulnar  nerve  at  elbow,  nor  along  its  course 
in  forearm.  Januar\-  14,  no  pain  since  last  visit.  Swelling  less,  but  cal- 
lus forming  around  condyles.  Not  tender  anywhere.  P21bow  passively 
extended  to  80  degrees,  and  again  dressed  in  hyperflexion.  January  28, 
in  sling;    rotation  of  forearm  nornial.     March  26,  flexion  to  80  degrees, 


Fin.   113. — Case  28.  Skiagraph  of  same  case,  lateral  view,  .'\ugust  20,  1907. 

extension  to  no  degrees;  a  bag  of  shot  was  fitted  on  the  boy's  hand,  so 
as  gradually  to  increase  extension.'  April  30,  active  flexion  to  50  degrees, 
and  active  extension  to  120  degrees.  August  20,  flexion  to  45  degrees, 
extension  to  140  degrees  (passive  extension  possible  to  150  degrees). 
There  is  marked  cubitus  valgus;  he  still  wears  the  shot  bag  at  times. 
The  fiftii  finger  cannot  be  actively  flexed  at  distal  interphalangeal  joint, 
though  the  other  joints  of  this  finger  are  normal.  Two  skiagraphs 
made  today  are  shown  in  Fig.  113  and  Fig.  114.  The  lateral  view 
(Fig.  113)  shows  only  a  little  periosteal  thickening  here  and  there;  the 
antero-posterior    view    (Fig.    114)    shows    marked    damage    to    external 


'  After  consultation  with  Dr.  G.  G.  Davis. 


DIACONnri.lR   IR.ICTLIRES 


133 


Pig.  114. — Case  2S.   Skiagraph  of  saint  cast-,  anttTo-postiilor  view,  August  20,  1907. 


Fig.   115.— Case  28.   Photograph  sliowuig  full  extension,  with  marked  ,ulntus  valgus,  after 
recovery  from  diacondjiar  fracture  of  the  type  "Posadas." 


134 


CI.IXICAL  lllSrOlilES 


condyle  above  capitelkim,  wlnile  the  epiphyseal  line  between  capitellum 
and  diaphvsis  of  humerus  appears  normal;  the  internal  cond\le  has  not 
been  so  much  damaged,  thus  accounting  for  the  cubitus  valgus.  October 
I,  a  Stromever  splint  was  applied,  to  increase  the  range  of  extension. 
Today  the  elbow  can  be  extended  passively  to  i6o  degrees. 

Result. — Examined  October  15,  1 907,  ten  months  after  injury.  Full 
flexion  and  full  extension;  carr\'ing  angle,  140  degrees  (Fig.  115).  Inter- 
nal condyle  thickened,  and  external  cond\le  displaced  upward.  Supina- 
tion and  pronation  normal.      Perfect  functional  use  of  elbow. 


Fig.   116. — Case  29.  Sklagrapl 


it  di.i. 


luh  l.ir  fracture  in  hvperflexion,  February  10,  1909. 


29.  Transverse  Diacondylar  Fracture  of  Left  Humerus. — Februar\-  8,  1909. 
James  G.,  aged  fourteen  years.  Fell  on  o\erextended  palm,  elbow  not 
fully  extended.  Symptoms:  Examined  within  one  hour;  pain  and  marked 
swelling  of  upper  third  of  forearm,  elbow,  and  lower  third  of  arm;  extent 
of  swelling  remarkable,  as  fall  had  been  broken  by  hand,  and  elbow 
had  not  struck  ground  at  all.  Great  tenderness  over  joint,  especially 
articular    end    f)f   humerus.     No    fracture    of    either    cond\le    or    above 


FRACTURES  OF  THE  EXTERNAL  CONDYLE 


135 


them.  No  distinct  crepitus.  Diagnosis:  Probably  epiphyseal  separation. 
TreatmcuU  Hvperflexion.  Skiagraph  (Fig.  Il6),  made  February  10, 
shows  transverse  diaconchlar  fracture,  commg  to  surface  above  e.xternal 
condyle,  and  entering  joint  on  inner  side,  below  internal  condyle.  Posi- 
tion good.  February  23,  extension  to  90  degrees.  March  29,  extension 
to  no  degrees. 

Result. — Examined  August  8,  1909.      Full  flexion  and  extension;  carry- 
ing'angle  normal.     Perfect  result. 


FRACTURES  OF  THE  EXTERNAL  CONDYLE. 

30.  Fracture  of  External  Condyle  of  Left  Humerus. — October  i,  1904. 
Harold  U.,  aged  ten  years.  Fell  several  feet,  but  does  not  know  whether 
he  landed  on  hand  or  f)n  elbow.  Symptoins  not  recorded.  Trfritiiwnt: 
Hyperflexion  for  about  three  weeks;   then  on  internal  angular  splint. 


Fig.   117. — Case  30.   Photograph  showing  full  flt-xion  after  recovery  from  fracture  of 

external  condyle. 

Result. — Examined  April  22,1909.  Is  now  fifteen  years  old.  Flexion, 
30  degrees;  extension,  187  degrees;  carrying  angle,  170  degrees;  all  same 
as  in  normal  elbow.  Figs.  117  and  118  are  from  photographs  made 
today.      Perfect  result. 

31.  Fracture  of  External  Condyle  of  Left  Humerus. — December  12, 
1904.  Louis  S.,  aged  two  and  one-half  \ears.  Injury  three  da\s  ago. 
Symptoms:  Much  cellulitis  and  abrasions  around  elbow.  Treatment: 
Right-angled  splint  to  outer  surface  of  arm.  Skiagraph  has  been  mislaid. 
December  31,  extension  to  135  degrees,  some  gunstock  deformit} . 

Result. — Cannot  be  traced. 


i;i(i 


CI.INIC.II.  IIISTOklES 


32.   Fracture  of  External  Condyle  of  Left  Eumervs.      November  25,  1905. 
William  S.,  :i"eil  tweUe  \ears.      WW  on  overexfeiuled  hand.      Sytiiptorns: 


Fig.   I  iS. — Ca.se  30.   I'liotofjrapli  showing  full  extension  alter  recovery  from  tracture  of 

external  conchle. 


Fig.  119. — Case  32.  .Skiagraph  of  fracture  of  external  condyle,  lateral  view, 
November  27,  1905. 

No  deformitv,  no  crepitus;    persistent  tenderness  over  external  condyle; 
no  abnormal  mobilitv.      Treatiiwiit:  Internal  angular  splint.     Skiagraph 


FRACTURES  OF  THE  EXTERNAL  CONDt'LE 


137 


(Fig.  119),  made  November  27,  shows  lateral  view  of  elbow,  seen  from 
inner  side;  line  of  fracture  passes  through  external  condyle  above  capitel- 
lum.  Skiagraph  (Fig.  120),  made  December  2,  shows  antero-posterior 
view  of  left  elbow,  seen  from  behind;  above  the  epiphyseal  line  sepa- 
rating capitellum  from  diaph\'sis  is  seen  a  line  of  fracture  which 
enters  joint  at  point  where  centre  for  capitellum  and  that  for  trochlea 
(which  last  is  barely  visible)  join;  the  outer  end  of  line  of  fracture  splits 
into  two  parts,  only  the  lower  extending  through  to  the  outer  surface 
of  humerus.  This  last  fissure  evidently  is  the  fracture  shown  in  Fig. 
iig.  Apparently  the  entire  fracture  is  subperiosteal,  as  the  only  s\  mp- 
tom  was  persistent  tenderness.  On  December  2,  the  elbow  was  put  in 
hyperflexion,  and  three  weeks  later  was  carried  m  a  sling  only. 


Fig.   120. — Case  32.   SIciagraph  of  fracture  of  external  condyle,  antero-posterior  view, 

December  2,  1905. 

Result. — Examined  January  23,  1907.  Full  extension,  full  flexion; 
carrying  angle  normal.  Perfect  result.  Fig.  121  is  from  a  photograph 
made  today. 

5j.  Fracture  of  External  Condyle  of  Left  Humerus. —  Julv  25,  1906. 
William  S.,  aged  three  \  ears.  Fell  off  porch  3  feet  high,  two  days  ago. 
Not  treated  before  today.  Syiiiptoiiis:  Swelling  and  ecchymosis;  crep- 
itus by  pressing  and  moving  external  condyle  on  inner.  Treatment: 
Hyperflexion.     August  21,  in  sling. 

Result. — Examined  September  4,  1906.  Full  flexion;  extension  very 
nearly  complete;  very  slight  gunstock  deformity,  external  condyle  being 
prominent  and  axis  of  forearm  being  about  5  degrees  to  inner  side  of 
that  of  humerus.  All  functions  normal.  Excellent  result,  considering 
two  days'  delay  in  seeking  treatment. 


138 


CLINICAL  HISTORIES 


Fig.   121. — Case  32.   Photograph  showing  full  extension  after  recovery  from  fracture  of 

external  cond\le. 


Fig.   122  — Case  j|.  Skiagraph  of  fracture  of  external  cond)le  in  h\perflexion, 

Octoher  30,  1906. 


FRACTURES  OF  TFIE  EXTERNAL  CONDYLE 


139 


34.  Fracture  of  External  Condyle  of  Right  Humerus. — October  27,  1906. 
John  15.,  aged  eleven  years.  Fell  two  weeks  ago;  treated  at  home  for 
sprain.  S\iupto)ns:  No  deformity,  but  persistent  pain  and  tenderness. 
Trcatnii'ut:  Hyperfle.xion.  Skiagraph  (Fig.  122),  made  October  30,  shows 
fracture  of  external  condyle,  without  displacement.  November  17,  in 
sling.     December  10,  extension  to  165  degrees. 

'Result. — F^xamined  June  8,  1907.  Full  flexion  and  extension;  carry- 
Perfect  result. 


Fig.   123. — Case  35.   Skiagraph  of  fracture  of  external  condyle,  at  right  angle, 

December  7,  1906. 


35.  Fracture  of  External  Condyle  of  Right  Humerus. — December  5,  1906. 
Harry  K.,  aged  five  years.  Fell  down  two  steps  on  palm  of  overex- 
tended hand.  Symptoms:  No  deformit\';  crepitus  over  external  cond\le, 
with  localized  pain,  swelling,  and  tenderness.  Treatment:  H\  perflexion. 
^Skiagraph  (Fig.  123),  made  December  7,  with  elbow  at  right  angle,  does 
not  show  fracture,  as  elbow  is  seen  laterally,  not  antero-posteriorlw  There 
apparently  is  also  an  injury  to  upper  end  of  ulna,  perhaps  impacted 
fracture,  from  compression  of  olecranon  in  olecranon  fossa  by  h}per- 
•extension  in  original  injury.  The  capitellum  is  well  seen,  and  the  centre 
for  the  head  of  radius  is  just  bareh'  visible.  December  26,  dressed  at 
right  angle.  January  3,  1907,  extension  possible  to  150  degrees;  wearing 
.sling. 


140 


CLINICAL  HISTORIES 


Result. — Examined  April  lo,  1907.      Full  flexion,  full  extension;  carry- 
ing angle  normal.     Perfect  result. 

36.  Fracture  of  External  Condyle  of  Left  Humerus. — January  12,  1907. 
Florence  S.,  aged  eight  years.  Accident  happened  January  10,  from 
fall  on  extensor  surface  of  flexed  forearm.  Picked  up  by  mother,  who 
says  forearm  was  in  extreme  pronation,  and  arm  in  extreme  inward 
rotation  after  fall;  and  that  as  she  twisted  arm  around  again  to  normal 
position  a  by-stander  heard  the  bones  grit.  Symptoms:  No  deformity, 
but  crepitus,  tenderness,  and  slight  mobility  of  external  condyle.  Skia- 
graph (unfortunately  lost),  made  January  13,  1907,  shows  fracture  of 
external  condyle,  frratiuoit:  Hyperflexion.  February  14,  extension  to 
135  degrees.  February  21,  extension  to  150  degrees;  supination  not 
quite  complete.  February  28,  extension  to  170  degrees;  probably  will 
have  a  little  cubitus  valgus. 


Fig.  124. — Case  37.  Skiagraph  of  fracture  of  external  condyle,  in  hyperflexion,  .April  2,  1907. 

Result. — Examined  February,  1908.  Full  flexion  and  full  extension; 
carrying  angle  normal,  no  cubitus  valgus.  Supination  complete.  Perfect 
result. 

37.  Fracture  of  External  Condyle  of  Left  Humerus. — March  31,  1907. 
Mildred  E.,  aged  five  years.  Symptoms:  Lower  fragment  (external 
condyle)  posterior,  with  radius;  upper  fragment  (shatt  of  humerus) 
forward  in  bend  of  elbow.  Treatment:  Hyperflexion.  Skiagraph  (Fig. 
124),   made  April   2,   shows  irregular  fracture  ot   external  condyle,  the 


FR.ICTURES  OF  TriF.  EXTERNAL  CONDYLE 


141 


elbow  (left)  being  viewed  from  inner  side  and  sliglitly  behind.  The 
only  centre  present  is  that  for  capitellum.  Shadows  cast  by  coronoid 
and  olecranon  tossas  can  be  clearly  seen  on  near  side  of  fracture.  April 
29,  in  sling. 

Result. — Plxamined  March  27,  1908.  Full  fle.xion  and  full  extension; 
carrying  angle  normal.  Perfect  result.  It  was  three  months  after  last 
note  before  full  extension  was  obtained. 

38.  Fracture  of  External  Condyle  of  Right  Humerus. — July  12,  1907. 
Daniel  McD.,  aged  three  years.  Fell  out  of  go-cart  yesterday;  probably 
landed  on  outer  side  of  extended  elbow;  certainly  did  not  land  on  out- 
stretched hand.  Symptoms:  Elbow  in  almost  complete  extension,  and 
forearm  in  almost  complete  supination.  Carr\  ing  angle  lost,  being 
about    180   degrees  (Fig.    125).      Tender   over  external    condyle,  which 


Fig.   125. — Case  38.   Photograph  showing  loss  of  carrying  angle  in  recent  fracture  of 
external  condyle  of  right  humerus. 

is  displaced  downward  and  forward;  internal  condyle  and  olecranon 
are  normal.  Marked  lateral  mobility  in  elbow-joint;  forearm  can  be 
abducted  beyond  normal  carrying  angle,  or  adducted  into  marked  cubitus 
varus,  as  external  condyle  glides  up  and  down  on  shaft.  Crepitus  is 
slight.  Internal  cond\le  is  solidh'  fixed  to  shaft,  excluding  both  supra- 
condylar and  intercondylar  fractures.  Treatment:  H\  perflexion.  August 
15,  in  sling;  extension  possible  to  1 10  degrees.  August  22,  extension  to 
135  degrees;  sling  stopped. 

Result. — Examined   September  21,   1908.      Full  Hexion  and  full  exten- 
sion; carrying  angle  normal.     Perfect  result. 


142 


CLINICAL  HISTORIES 


39.  Fracture  of  External  Condyle  of  Left  Humerus. — August  14,  1907. 
James  McG.,  aged  two  and  one-halt  \ears.  Pell  \esterdav  out  ot  go- 
cart;  it  is  not  known  how  he  landed.  Pain  in  elbow  all  night.  Symptoms: 
Holds  elbow  in  nearh  complete  extension,  with  forearm  in  semipronationr 
moves  whole  extremity  from  shoulder.  Carrying  angle  lost,  forearm 
being  in  straight  line  with  arm.  Klbow  swollen,  especially  over  external 
condyle  and  under  supinators.  Black  and  blue  over  external  cond\le, 
which  seems  displaced  a  little  backward  and  downward.  Tender,  but 
no  crepitus,  though  condyle  can  be  moved  shghth'  antero-posteriorh 
on    shaft.     No    e\idence    of   supracond\Iar    fracture.      Fig.     126,    from- 


Fig.   126. — Case  39.   Photograph  showing  loss  of  carrying  angle  in  recent  fracture  of 
external  cond\le  of  left  humerus. 


photograph  made  on  admission,  shows  loss  ot  carr\  ing  angle.  Treat- 
ment: H\  perflexed,  and  cubitus  valgus  forcibly  restored  by  abducting 
forearm  during  this  manoeuvre.  September  3,  extension  to  no  degrees. 
September  7,  extension  to  120  degrees. 

Result. — Examined  September  18,  1908.  Full  flexion  and  full  exten- 
sion;  carrying  angle  normal.      Perfect  result. 

40.  Fracture  of  External  Condyle  of  Left  Humerus. — September  7,  1907. 
Joseph  S.,  aged  6  \ears.  Fell  yesterday  off  velocipede,  landing  on  outer 
surface  of  left  elbow,  which  was  fulh  extended.  Fracture  thus  was 
caused  by  excessive  adduction  of  forearm,  hand  and  shoulder  being  in 
contact  with  ground,  and  weight  of  body  coming  on  apex  of  triangle 
formed   by   arm   and   forearm   at  elbow   (Fig.    56).     Symptoms:    Whole 


FRACTURES  OF  THE  EXTERNAL  CONDri.E 


143 


extremity  is  moved  from  shoulder;  no  spontaneous  motion  ;it  elbow. 
Elbow  is  nearly  full  extension;  carrying  angle  lost  (Fig.  127).  On  right 
side  carrying  angle  is  170  degrees.  Ecchymosis  over  external  condyle. 
Free  lateral  mobilit\  in  elbow,  as  detached  condyle  slides  up  and  down 
on  shaft;  this  is  onl\-  motion  which  is  painful,  except  full  flexion  and 
h\perextension.  Eocali/.ed  tenderness  over  external  cond\le,  crepitus, 
and  abnormal  mobilitw  Trnitiucnt:  Hyperflexion,  with  restoration  of 
carrying  angle  by  abduction  ot  forearm.  September  10,  redressed;  much 
less  swelling;  no  pain. 


Fig.   127. — Case  40.  Photograph  showing  loss  of  carrying  angle  in  recent  fracture  of 
external  condyle  of  left  humerus. 

Result. — Mother  reports,  September  22,  IQ08,  that  elbow  can  be  fully 
flexed  and  extended,  and  that  carr\  ing  angle  is  normal.      Perfect  result. 

41.  Fracture  of  External  Condyle  of  Left  Humerus. —  |ul\  21,  1909. 
Robt.  O'N.,  aged  three  years.  Fell  o\\'  bed  vesterda\  ;  it  is  not  known 
how  he  landed.  Dressed  b\'  resident  on  internal  angular  splint.  Symp- 
toms: Carrying  angle  lost;  forearm  can  be  adducted  to  210  degrees, 
and  abducted  to  150  degrees,  there  being  lateral  motion  of  sixt\-  degrees 
without  causing  much  pain.  Crepitus  on  back-and-forth  movements 
to  forearm.  External  condyle  forward  and  down,  moves  treelv  with 
crepitus  on  shaft;  internal  condyle  attached  to  shaft.  Treatment:  Hyper- 
flexion, with  abduction  to  overcome  cubitus  varus. 

Result. — Report,  October  24,  190Q.  Full  flexion  and  full  extension; 
carrying  angle  normal. 


144 


CLINICAL  HISTORIES 


FRACTURES  OF  THE  EPITROCHLEA. 

4>.   Separation    of    Epitrochlea    of    Left    Humerus. ^Januan     i8,    1904. 
Harold  N.,  aged  twelve  years.     Fell  January  8,  1904,  striking  on  eliiow. 


Fig.  128. — Case  42.  Skiagraph  of  separ- 
ation of  epitrochlea  of  left  humerus,  antero- 
posterior view,  February  6,  IQ04. 


Fig.  129. — Case  42.  Skiagraph  of 
separation  of  epitrochlea  of  left  humerus, 
lateral  view,  February  6,  1904. 


Fig.  130. — Case  42.  Skiagraph  of  separ- 
ation of  epitrochlea  of  left  humerus,  antero- 
posterior view,  April  22,  1907. 


Fig.  131. — Case  43.  Skiagraph  of  separ- 
ation of  epitrochlea  of  right  humerus, 
two  and  one-half  years  after  injury,  April 

28,  1907. 


JR.ICTURJiS  OF  THE  lil'ITIiOCI I I.EA 


145 


Treatetl  elsewhere  as  recent  accident.  Symptoms  (January  l8):  Elhow 
stiftand  painful.  Treatment:  H\perflexion.  Skiagraph  (Fig.  129),  made 
February  6,  shows  lateral  view  of  left  elbow;  centres  for  head  of  radius 
and  for  olecranon  are  seen  in  normal  places;  overlapping  shadow  of 
greater  sigmoid  fossa  of  ulna  is  abnormal  shadow,  which  from  antero- 
posterior view  (Fig.    128)  is   seen   to   be  centre  for   epitrochlea;   in   the 


Fig.   132. — Case  44.   Skiagraph  of  separation  of  epitrochlea  of  left  luinicrus, 
September  30,  1904. 

antero-posterior  view  it  shows  between  shadow  of  ulna  and  that  for 
centre  tor  trochlea,  which  latter  it  overlaps.  This  is  a  front  view  of 
left  elbow.      Compare   Cases  44  and    28. 

Result. — Examined  April  22,  1907.     No  deformit\',  all  functions  perfect. 
Perfect  result.     Skiagraph  made  this  day  (Fig.  130)  shows  lack  of  bon\ 
development  of   epitrochlea,  and    distmct  shadow  from   displaced   frag- 
ment; this  is  a  rear  view  of  left  elbow. 
10 


140  CLINICAL  HISTORIES 

43.  Separation  of  Epitrochlea  of  Right  Humerus. — September  28,  1904. 
Harry  II.,  aged  twelve  \ears.  Pell  011  overextended  palm,  with  elbow 
extended.  Symptoms  not  recorded.  Trcatntrnt:  I  hperflexion,  tor  four 
weeks. 

Result. — P^xamined  April  28,  1907.  Full  flexion;  exten.sion  to  175 
degrees  (practically  complete);  supination  and  pronation  complete;  no 
callus,  no  deformity;  carrying  angle  normal.  This  amount  of  extension 
was  not  obtained  for  six  months  after  treatment  was  stopped.  Skia- 
graph (Fig.  131),  made  toda\-,  viewing  right  elbow  from  within  and 
posteriorly,  shows  old   injur\    to  epitrochlea,  not  involving  trochlea. 

44.  Separation  of  Epitrochlea  of  Left  Humerus,  Complicating  Posterior 
Dislocation  of  Ulna. — September  29,  1904.  Arthur  T.,  aged  fourteen 
years.  Fall  on  hand;  dislocation  reduced  by  resident  ph\sician.  No 
symptoms  from  fracture,  which  was  discovered  only  b}'  stud\-  of  skiagraph 
(Fig.  132),  where  irregular  fracture  through  olecranon  is  also  seen  (sub- 
periosteal), and  the  displaced  epitrochlea  can  be  discerned,  as  in  Case 
42,  overlapping  shadows  of  olecranon  and  of  trochlea.  Compare  also 
Case  28.      Treatment:  Hyperflexion. 

Result. — Patient  cannot  be   traced. 


SEPARATION  OF  LOWER  EPIPHYSIS  OF  HUMERUS. 

45.  Separation  of  Lower  Epiphysis  of  Right  Humerus. — September  23, 
1904.  Elmer  L.,  aged  nine  years.  Fall.  Symptoms  not  xecordeA.  Skia- 
graph (Fig.  133).  taken  after  dressing  elbow  in  h\perflexion,  shows  no 
line  of  fracture;  the  line  of  separation  passed  through  the  epiphyseal 
cartilage,  and  the  epiph\sis  has  been  replaced  in  normal  position  by 
hyperflexion.  The  elbow  (right)  is  viewed  from  inner  and  posterior 
aspect;  the  centre  for  capitellum  of  humerus  is  easily  seen,  and  that  for 
head  of  radius  indistincth  ;   the  other  centres  have  not  yet  appeared. 

Result. — This  patient  cannot  be  traced. 

46.  Separation  of  Lower  Epiphysis  of  Left  Humerus. — .August  23,  1904. 
Eleanor  iMcG.,  aged  three  \ears.  From  fall.  Sxmptoms  not  recorded. 
Treatment:  Hyperflexion.  Skiagraph  (Fig.  134),  made  next  day,  show- 
ing left  elbow  viewed  from  behind,  with  forearm  in  pronation,  shows 
shell  of  bone  torn  loose  from  diaphysis  above  centre  for  capitellum, 
which  can  be  discerned  overlapping  shadow  cast  by  upper  end  of  ulna. 

Result. — This  patient  cannot  be  traced. 

47.  Separation  of  Lower  Epiphysis  of  Left  Humerus. — October  14,  1905. 
Frank  S.,  aged  eleven  \ears.  From  tall.  Symptoms:  It  is  noted  that  at 
end  of  ten  days  there  is  a  loose  fragment  in  flexure  of  elbow,  at  inner 
side.     Skiagraph  (Fig.  135)  shows  moderate  displacement  of  epitrochlea, 


EPIPHYSEAL  SEPJR.rrJONS 


147 


and  some  irregularit\  of  epiph}'seal  line  lietween  capitelluiii  and 
diaphysis.  Centre  tor  trochlea  has  not  \et  appeared;  that  for  capitelliini 
is  in  normal  place.  Tri'atniciit:  H\perHexion.  Skiagraph  (Fig.  1^6), 
made  December  12,  1905,  shows  epitrochlea  apposed  to  diaphysis, 
though  below  its  normal  site;  also  an  irregular  mass  of  callus  over 
external  cond\le,  apparenth'  arising  from  epiphyseal  line  between  capi- 


FiG.   133. — Case  45.   Skiai>iapli  of  epiplnseal  separation  of  right  liumerus, 
September  23,   iq04. 

tellum  and  diaphysis.  Periosteum  has  also  been  stripped  up  from  shaft 
above  external  condyle,  and  a  faint  shadow  of  newl\-  formed  bone  is 
seen  beneath  it. 

Result. — Kxamined  February  12,  1908.  Full  extension  and  flexion 
and  rotation;  carrying  angle  normal.  A  little  thickening  over  internal 
condyle.      Perfect  result. 


us 


CLINICAL  lIlSTOlilLS 


48.   Separation  of  Lower  Epiphysis  of  Right  Humerus. — lanuary  10,  1907. 
Irene   H.,  aged  two  \ear.s.      Accident  happened    |anuarv  C);  fell  oft'  table 


Fig.   134. — Case  46.   Skiagraph  of  t piphyseal  separation  of  left  humerus,  August  23,  1904. 


Fig.  135. — Case  47.  Skiagraph  of  epi- 
physeal separation  of  left  humerus, 
October  14,  1905. 


1- IG.  136. — Case  47.  Skiagraph  of  epi- 
physeal separation  of  left  humerus,  Decem- 
ber 12,  IQ05. 


I:l'l I'll)  SEAL  SIJ'  IR.rnONS 


]4!t 


Fig.  137. — Case  48.   Skiajirapli  ofepiphyseal  separation  of  right  humerus,  January  10,  IQ07. 


Fig.   138. — Case  48.   Photograph  showing  cubitus  valgus,  after  recovery  from  epiphyseal 
separation  of  right  humerus,  March  28,  1908. 


150 


CIJNICU.  ff/STOklhS 


on  to  elbow,  forearm  being  flexed  at  right  angle.  Sviiiptonis:  Elbow  beld 
rigid  at  right  angle;  very  painful,  somewhat  hot,  and  on  extension  and 
flexion  there  is  moist  crepitus,  and  slight  sensation  of  abnormal  mobility; 
flexure  of  elbow  seems  fuller  than  normal.  Skiagraph  (Fig.  137),  made 
January  10,  excludes  supracondylar  fracture;  as  line  of  separation 
runs  through  cartilage  (epiph\seal  line),  it  is  not  \isible.  Treatment: 
Hyperflexion.  Februar\  7,  in  sling.  Februar\  14,  still  tender;  ichthvol 
ointment  applied.  P'ebruarx  25,  does  not  use  it  much  yet;  extension  to 
IJ5  degrees.  April  11,  extension  to  145  degrees,  flexicjn  to  70  degrees; 
uses  it  more.  April  29,  extension  to  150  degrees,  flexion  to  70  degrees; 
uses  it  normalh-;  slight  nihittis  valgus. 


Fig.  139. — Case  49.  Skiagraph  ot  epi- 
physeal separation  of  right  humerus, 
lateral  view,       March  31,  1909. 


Fig.  140. — Case  49.  Skiagraph  of  epi- 
phiseal  separation  of  right  humerus, 
antero-posterior  view,  March  31,  1909. 


Result. — Examined  March  28,  iQoS.  Flexion  normal;  extension 
to  170  degrees;  carrying  angle,  160  degrees,  that  of  normal  left  elbow 
being  180  degrees.  The  slight  cubitus  valgus  is  shown  in  Fig.  138, 
from   photograph   made   toda\ . 

If  the  diagnosis  in  this  case  had  been  made  from  the  skiagraph  alone, 
the  conclusion  would  have  been  that  no  injury  to  the  elbow-joint  was 
present.  The  resulting  detormit\',  however,  confirms  the  existence  of 
epiphyseal  separation,  this  diagnosis  being  based  purely  on  the  clinical 
symptoms. 

4g.  Separation  of  Lower  Epiphysis  of  Right  Humerus. — March  30,  1909. 
William  D.,  aged  twelve  years.      Fell   12  feet  last  night,  landing  on  over- 


EPIPHYSEAL  SEPARATIONS 


151 


extended  jialni.  S\iiipt<jii/s:  Tender  over  both  cond\  les,  especially  over 
internal;  no  crepitus,  no  abnormal  mobility;  neither  condyle  movable; 
no  fracture  above  condyles.  Trcatvicut:  Hyperflexion.  Skiagraph 
(Fig.  140),  made  March  31,  shows  irregular  fracture  through  lower 
border  of  diaphysis  above  capitellum,  thence  passing  into  epiphyseal 
line  at  a  point   between  trochlea  and    shaft;    the  centre  tor  trochlea   is 


Fig.   141. — Case  50.    Skiagraph  of  epipliyscal  separation  of  left  humerus,  antero-posterior 

view,  April  7,  iipq. 


■)li\sioloeical  riilntiis  vahus  is  exaggerated; 


displaced  toward  ulna,  ai 
centre  for  epitrochlea  is  detached.  April  5,  numb  over  extensor  surface 
of  thumb,  index,  and  half  of  ring  fingers,  at  tips  (distribution  of  median 
nerve),  and  also  over  ulnar  distribution  to  ring  and  little  fingers.  April 
16,  no  anaesthesia;  still  dressed  in  h\  jierflexion.  April  IQ,  in  sling; 
ecch\mosis  has  appeared  over  internal  cond\le  and  up  mner  surface 
of  humerus.     April  22,  in  sling  still;    extension  to   130  degrees.     April 


152  CLINICAL  HISTORIES 

26,  flexion  to  ^5  degrees,  extension  to  155  degrees.  May  6,  flexion,  33 
degrees;  extensif)n,  175  degrees;  carr\'ing  angle  normal. 

Result. — Flxamined  August  8,  1909.  Full  flexion  and  extension;  carry- 
ing angle  normal.      Perfect  result. 

50.  Separation  of  Lower  Epiphysis  of  Left  Humerus. — April  6,  1909. 
Charles   N.,  aged  eleven  years.      Fell   \esterda\   on  overextended   palm, 


Fig.   142. — Case  50.   Skiagraph  of  tpipln  seal  icpai.itiuii  ul  ktt  liumtrus,  lateral  view, 

April  7,  1909. 

and  elbow  suddenh'  flexed;  immediately  experienced  pain,  swelling, 
and  limitation  of  motion  at  elbow.  Dressed  by  resident  physician  in 
hyperflexion.  Symptoms  (April  7):  No  crepitus,  no  abnormal  mobilit\-; 
carrying  angle  normal  on  full  extension;  excluded  fracture  above  con- 
dyles or  itracture  of  either  condyle.     Diagnosis:    Contusion.     Skiagraph 


El'IPIirSRAL  SEI'.I  RAT  IONS 


153 


(Fig.  141),  made  April  7,  shows  that  a  shell  of  hone  has  heen  torn  oft" 
diaphysis  above  centre  tor  capitelluni  ot  humerus.  Revised  diagnosis: 
Epiphyseal  separation.  Treatment:  Hyperflexion  continued.  April  19, 
black  and  blue  over  external  condyle  and  head  of  radius.  April  26, 
extension  possible  to  go  degrees;    still  dressed  in  hyperflexion. 

Result. — August  8,   1909.      Brother  reports  full   flexion  and  extension; 
carrying  angle  normal.     Perfect  result. 


Fig.  143. — Case  51.  Skiagraph  of  epiphyseal  separation  of  left  humerus,  hiteral  view, 

July  8,   1909. 


51.  Separation  of  Lower  Epipliysis  of  Left  Humerus.  July  8,  1909. 
Joseph  C,  aged  eighteen  months.  Yesterday  mother  grasped  child  by 
left  elbow,  which  was  fully  extended,  and  picked  him  up  off  the  floor. 
As  she  did  so  she  heard  a  snap,  but  thought  little  of  it  until  child  cried 
all  night,  and  still  had  pain  in  elbow  this  morning.  Symptoms:  Per- 
sistent tenderness  in  joint,  especialh'  in  fold  of  elbow;  no  abnormal 
mobilitv,  no  lateral  mobilit\';  moist  crepitus  in  flexion  and  extension. 
Diagnosis:  Epiphyseal  separation.  Skiagraph  (Fig.  143),  made  same 
day,  shows  no  line  of  fracture;  probabl\-  faint  line  in  position  of  dia- 
condylar  fracture  is  from  defect  in  plate,  and  true  line  of  separation  is 
entirely  cartilaginous,  and  so  casts  no  shadow.  Treatment:  Hyper- 
flexion.    July  29,  in  sling. 


154 


CLINICAL  HISTORIES 


Result.— ¥.x:im\r\t A    August    i^j,     iQog.     Full    flexion    and    extension; 
carrying  angle  normal. 


Fig.  1+4. — Case  51.   Skiagraph  of  epiphyseal  separation  of  left  humerus,  antero-posterior 

view,  July  8,  igog. 


FRACTURES  OF  THE  INTERNAL  CONDYLE. 


52.  Fracture  of  Internal  Condyle  of  Humerus. — September  12,  1903. 
Joseph  R.,  aged  42  years.  Injury  two  weeks  ago.  Syniptovis  not 
recorded.     No  notes. 

Result. — This  patient  cannot  he  traced. 

53.  Fractiu-e  of  Internal  Condyle  of  Left  Humerus. — April  28,  1904. 
George  S.,  aged  seventeen  \ears.  Fell  on  internal  cond\le  of  left 
humerus,  with  elbow  in  acute  flexion.  Dressed  b\'  resident  on  internal 
angular  splint.  Seen  bv  me  next  da\'.  Symptoms:  Great  swelling  of 
elbow,  mobility  and  crepitus  of  internal  condyle.  Skiagraph  (Fig.  145) 
shows  fracture  of  epitrochlea  and  outer  surface  of  trochlea,  in  one  piece, 
with  complete  rotation  of  the  fragment  on  its  longitudinal  axis.  Treat- 
ment: Hyperflexion  for  five  weeks;  then  in  a  sling  for  short  time.  There 
was  no  injury  of  ulnar  nerve. 


FRACTURES  OF  THF  INTERNAL  CONDYLE 


155 


Result. — Kxamineil    April    27,    1907,    three    years    after    tlie    fracture. 
Full  flexion;  extension  only  to   150  degrees;     sujMnarion   and   pronation 


Fig.  145. — Case  53.   Skiagraph  of  fracture  ot  iiitirnal  contUle  of  left  liumerus, 

April  28,  iqo4. 


I 

> 

1 

■  ■ 

^^^V'ii 

Fig.  146. — Case  53.  I'hotugrapli  showing 
cubitus  valgus  after  recovery  from  fracture  of 
internal   condyle,  April  27,  igO/. 


Fig.  147. — Case  53.  Skiagraph  of 
old  fracture  of  internal  condyle, 
April  27,  1907. 


complete;     slight   cubitus  valgus,   about    U^o   degrees   (Fig.    146).     The 
.epitrochlea  is  displaced  downward  3.5  cm.,  compared  with  other  arm. 


15() 


CLIN  I  C.I  I.  HIS  TORI  ES 


There   is   no   disability.     Skiagraph    today    (Fig.    147)    shows   fragment 
still  displaced;    also  indicates  the  degree  of  extension. 

This  case  would  at  present  be  considered  one  suitable  for  operation 
to  correct  rotation  of  fragment  in  recent  fracture.  In  the  endeavor 
to  avoid  gunstock  deformitN  (especialh'  to  be  feared  in  fractures  of 
internal  condyle)   I   produced  nihitta  valgus,  which,  however,  is  much 


Fig.  148. — Case  55.  Skiagraph  of  fracture  of  internal  condyle  of  right  humerus,  lateral 

view,  January  8,  1909. 

less  disabling,  and  caused  this  patient  no  inconvenience  whatever  in  his 
work.  Even  with  operation  it  is  doubtful  if  a  better  functional  result 
could  have  been  obtained. 

54.  Fracture  of  Internal  Condyle  of  Left  Humerus. — December  8,  1904. 
Harry  D.,  aged  two  years.  5 v"'/'/o/?/j  not  recorded.  Treatment:  Hyper- 
flexion. 

Result. — Examined  January  3,  1905.  Full  flexion  and  extension; 
carrying  angle  normal. 


FRACTURES  OF  THE  INTERN JE  CONDl'EE 


157 


55.  Fracture  of  Internal  Condyle  of  Right  Humerus. — Januarv  7,  1909. 
Stanley  S.,  aged  fourteen  \ear,s.  Fell  on  point  of  Hexed  elbow.  Symp- 
toms: Swelling;  mobilit\  of  internal  cond\le  on  shaft;  no  fracture  above 
condyles;  no  injur\  to  external  condyle  detected.  Trcdtincnt:  l!\per- 
flexion.      Skiagraph  (Fig.    14S),   made    January  8,  shows  good    position; 


Fig.   149. — Case  55.   Fracture  of  internal  condyle  of  right  humerus,  tliree  months 
after  injury  (antero-posterior). 


also  slight  separation  of  epiph\  sis  of  olecranon.  |anuar\  25,  dressed  at 
right  angle.  Februar\-  12,  extension  to  115  degrees.  March  28,  flexion 
to  45  degrees,  extension  to  140  degrees.  April  5,  skiagraph  (Fig.  149) 
shows  considerable  thickening  in  joint;  apparently  injurv  was  separa- 
tion of  epiph\sis  of  trochlea,  epitrochlea,  and  olecranon.  Periosteum  is 
stripped  from  diaph\  sis  abo\  e  ejiitrochlea.  ."Xprd  26,  flexion  to  40  degrees, 
extension  to  150  degrees. 


158 


CLINIC.1L  HISTORIES 


Remit. — August  I  ^,  190Q.  Full  flexion  and  extension;  carrying  angle 
normal. 

INTERCONDYLAR  FRACTURE. 

56.  Intercondylar  Fracture  of  Right  Humerus. — January  17,  1904.  Mike 
C,  aged  twenty-eight  years.  Intoxicated;  does  not  know  how  he  was 
injured.  Symptoms:  Internal  condyle  down  and  forward;  crepitus  and 
mohilit)  of  internal  cond\  le  on  shaft.  No  injury  to  external  condyle  de- 
tected clinically.      Treatment:  Hyperflexion.     Skiagraph  (Fig.  150),  made 


Fig.  150. — Case  56.  Skiagraph  of  intercondylar  fracture  of  right  humerus,  antero-posterior 

view,  February  Q,  i0O4- 


February  9,  "1904,  twenty-three  days  after  injury,  shows  full  extension 
of  forearm  on  arm,  with  internal  condyle  split  oft,  joint  being  entered 
through  trochlear  surface;  also  a  fracture  ot  external  condyle,  appar- 
ently impacted.     Slight  gunstock  deformity  seen  in  skiagraph. 

Result. — Full    extension,    with    slight   gunstock    deformity    at   end    ot 
three  weeks;    impossible  to  trace  patient  further. 


INDEX    OF    NAMES 


Alexander,  86 

Allis,  17,  72,  77,  81,  97 


Bardenheuer,  72 

Barlatier,  i  7,  18,  38,  51,  87,  93,  94,  95,  96,  97 

Berthomier,  72 

Billroth,  42 

Brewer,  18,  97 

Broca,  87 


Carless,  19 

Cliutro,  17,  18,  38,  42,  62,  67,  74,  79,  80,  81 

86,  88,  89,  97 
Coenen,  19,  71,  81,  87,  93,  94,  96,  97 
Cooper,  Astley,  88 
Cotton,  17,  18,  38,  81,  93,  94,  96,  97 
Cruveilliier,  42 


Da  Costa,  18,  97 

Dauvergne,  42,  72,  88,  97 

Davis,  G.  G.,  81,  97,  1 12,  132 

Destot,  17,  18.  38,  51,  87,  93,  94,  95,  96,  97 

Dupuytren,  62 

Dwigiit,  31 


Eisendrath,  19,  41,  97 
Eve,  19,  97 


Lane,  17,  72,  97 
Listen,  72 
Ludloft,  19 
Lusk,  64,  97 


Madelung,  86 

Miles,  19 

Mouchet,  17,  18,39,49,68,78,79,81,87,98 

Mailer,  38,  87,  98 


Pezerat,  72 
Physick,  71 
Pilcher,  18,  98 
Pitha,  42 

Posadas,  42,  131,  133 
Potter,  28,  98 


Roberts,  17,  19,  72,  86,  1 
Rose,  19 


Scudder,  19,  41,  98 
Siter,  20,  98 
Smith,  H.  H.,  26 
Smith,  H.  L.,  88,  98 
Stewart,  18,  98 
Stimson,  17,  49,  73,93, 


Gibbon,  88 
Gurlt,  49,  86 


Hartshorne,  71 

Heusner,  72 

Hilgenreiner,  68,  81,  93,  94,  95,  97 

Hippocrates,  91 


Jones,  R.,  88,  97 
Judet,  38,  97 


Kocher,  26,  38,  39,  41,  56,  62,  73,  81,  97 


Thomas,  H.  O.,  88 
Thomas,  ].  J.,  87,  1 
Thomson,  19 
TifFany,  19,  98 


Velpeau,  88 

Vignard,  17,  18,  38,  51,  87,  93,  94,  95,  96,  97 

Volkniann,  87 


Wharton,  18,  c 
Wilms,  19,  98 
Wolff,  80 


GENERAL  INDEX 


Acute  fltxion  of  elbow,  88 
Anaesthetics,  use  of,  in  diagnosis,  59 
Anatomy,  20 
Angle,  the  carrying,  27 
Arthrolysis  for  ancient  fracture,  66 


Bibliography,  97 
Bulla-,  56 


Diacondylar  fractures,  case  histories,  122 

mechanism,  73 

pathological  anatomy,  74 

results,  75 

symptoms,  74 

treatment,  75 
Diagnosis,  use  of  anaesthetics  in,  59 
Diaphysis  of  humerus,  30 
Dislocation   of  elbow,  differential   diagnosis, 

62 
Dressing  the  elbow  in  hyperflexion,  88 


Callus,  excessive,  92 

Capitellum,  21 
centre  for,  30 
fracture  of,  49 

Capsule  of  elbow,  attachments  of,  23 

Carrying  angle,  27 

Case  histories  of  diacondylar  fracture,  122 
of  epiphyseal  separation,  146 
of  epitrochlear  fracture,  144 
of  external  condylar  fracture,  135 
of  intercond\lar  fracture,  Ij8 
of  internal  condylar  fracture,  154 
of  supracondylar  fracture,  loi 

Centres,  epiphyseal,  30 

Classification,  37 

Clinical  histories,  99 

Complications,  87 

Condyle,  external,  21 
internal,  21 

Contracture,  isch.cmic,  87 

Coronoid  fossa,  20 

Crepitus,  examination  foj,  57 

Cubitus  valgus,  physiological,  28 

pathological,  cases  of,  133,  149,  155 
varus,  29 

cases  of,  127,  158 

in  recent  fractures  of  external  con- 
dyle, 141,  142,  143 


D 


Development    of   lower    epiphysis    of   hu- 
merus, 30 
Diacondylar  fractures,  41,  73 
11 


ECCHYMOSIS,  56 

Epicondyle,  21 
centre  for,  30 
fracture  of,  49 
Epiphyseal  centres,  appearance  of,  30 
line,  30 
separations,  42,  79 

case  histories,  146 
mechanism,  79 
pathological  anatomy,  80 
results,  81 
symptoms,  79 
treatment,  81 
Epiphysis,  lower,  ot  humerus,  development  of, 

Epitrochlea,  21 
centre  for,  30 
fractures  ot,  42,  78 

case  histories,  144 
mechanism,  78 
pathological  anatomy,  78 
results,  79 
symptoms,  78 
treatment,  79 
Examination  of  patients,  56 
Extension,  fractures  by,  38 

normal  limit  of,  in  elbow,  24 
External  condyle,  fractures  of,  42, 
case  histories,  135 
mechanism,  75 
pathological  anatoiTi\',  76 
results,  77 
symptoms,  76 
treatment,  77 
ununited,  88 


75 


1(52 


GENERAL  INDEX 


Flexion,  fratriux-s  by,  39 

normal  limit  of,  in  elbow,  24 
position  of  acute,  88 
Fracture  of  capitelluni,  49 
diacondylar,  41,  73 

case  histories,  i  22 

comminuted,  case  ot,  124 

by  "flexion,"  case  of,  124 

('■  Posadas"),  42 
case  of,  129 
of  epicondyle,  49 
of  epitrochiea,  42,  78 

case  histories,  144 
of  external  condyle,  42,  75 

case  histories,  135 

ununited,  88 
intercondylar,  48,  86 

case  history,  158 
of  internal  condyle,  46,  81 

case  histories,  154 
of  lower  third  of  humerus,  39 
supracondylar,  38,  60 

case  histories,  loi 

comminuted,  case  of,  108 
"T,"48 
of  trochlea,  49 

■■Y."48 
Frequency,   relative,  of  various  elbow   frac- 
tures, 38 


GONIOMETFR,  92 

Gunstock  deformity,  29 
Gymnastics,  91 

H 

History  of  patient's  injury,  56 
Hyperflexion  of  elbow,  88 


Immobilization,  prolonged,  92 
Inspection  of  injured  elbow,  56 
Intercondylar  fractures,  48,  86 

case  history,  158 

mechanism,  86 

pathological  anatomy,  86 

results,  87 

symptoms,  86 

treatment,  86 
Internal  condyle,  fractures  of,  46,  81 

case  histories,  154 

mechanism,  53,  82 

pathological  anatomy,  82 

results,  85 

symptoms,  82 

treatment,  83 


Joint,  limits  of  elbow,  25 
radio-ulnar,  23 


Ligament,  cajisular,  23 

lateral,  24 

orbicular,  24 
Limitation  of  motion  in  normal  elbow-joint,  24 
after  fracture  of  elbow,  93 


M 


Massage,  91 

Mechanism  of  elbow  fractures,  49 
of  epiphyseal  separations,  79 
of  fracture  of  capitellum,  52 
diacondylar,  53,  73 
of  epitrochiea,  52,  78 
of  external  condyle,  75 
by  abduction,  52 
by  adduction,  ^5 
by  fall  on  hand,  50 
intercondylar,  86 
of  internal  condyle,  53,  82 
supracondylar,  61 

by  fall  on  hand,  51 
Median  nerve,  paralysis  of,  87 
Mobility,  examination  for,  57 
Motion,  limitation  of,  in  normal  elbow,  24 
Movements,  passive,  92 
Musculo-spiral  nerve,  paralysis  of,  87 


N 

Nerve  lesions,  87 

examination  for,  57 
Neuritis  of  median  nerve,  87 
operation  for,  1 1 


O 

Olecranon,  centre  for,  30 
fossa,  20 


Palpation  of  injured  elbow,  57 
Passive  movements,  91 
Pathogenesis  of  elbow  fractures,  49 
Pathological   anatomy  of  epiphyseal   separa- 
tions, 80 
of  fractures,  diacondylar,  74 
of  epitrochiea,  78 
of  external  condyle,  76 


GENERAL  INDEX 


163 


Pathological     anatomv    of    fractures,    inter- 
condylar, 86 

of  internal  conilv'lc,  82 

supracondylar,  0^ 
Patients,  examination  o(,  56 
Periosteum  stripped  from  Inimerus,  64 
Posadas,  diacondylar  fracture  of,  42 

case  of,  I2Q 
Position  of  greatest  stability,  26 
Prognosis,  current  teaching  as  to,  18 


R 


Radial  nerve,  paralysis  of,  87 
Radius,  centre  for  head  of,  30 
References,  table  of,  qy 

Results  in  cases  of  epiphyseal  separations,  81 
in  fracture,  diacondylar,  75 

of  epitrochlea,  79 

of  external  condyle,  77 

intercondylar,  87 

of  internal  condyle,  85 

supracondylar,  72 
tabular  statement  of,  94 


Separation  of  lower  epiphysis  of  humerus, 
42,89   \ 
case  histories,  146 
Skiacraphs,  interpretation  of,  59 
Stability,  position  of  greatest,  26 
Supracondylar  fractures,  38,  60 
case  histories,  101 
mechanism,  61 
pathological  anatomy,  63 
results,  72 
symptoms,  62 
treatment,  68 
Swelling,  after  application  of  dressing,  91 
before  application  of  dressing,  88 


Symptoms  of  diacondylar  fracture,  74 
of  epiphyseal  separation,  79 
of  fracture  of  epitrochlea,  78 

of  external  condyle,  76 

intercondylar,  86 

of  internal  condyle,  82 

supracondylar,  62 


"T"  FRACTURES,  48,  86 

Treatment  of  diacondylar  fracture,' 75 
of  epiphyseal  separation,  81 
of  fracture  of  epitrochlea,  79 
of  external  condyle,  77 
intercondylar,  86 
of  internal  condyle,  83 
supracondylar,  68 
Trochlea,  21 

centre  for,  30 


U 


Ulnar  nerve,  paralysis  of,  87 
Ununited  fracture  of  external  condyle. 


Valgus,  physiological  cubitus.  28 

Velpeau's  position,  88 

Volkmann's  ischaeniic  contracture,  87 


X-RAYS,  interpretation  of,  59 


'Y"   FRACTURES,  48,  86 


Date  Due 


APR< 

121976 

ftpU    ' 

pFH'li 

MAY   1  i 

Ml 

nni  1  ^ 

mi 

'\:'  :  9 

1981 

University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


SRLF 
2  WEEK 


h 


OCT  28  W 


PRINTED   IN    U.S.. 


CA 


<i>i 111'] iDti HHIill illi iViii ''111' i''li iv'' IV 


g-:S"29  719  JL 


-  WE810 

A825a 

iS/0 

act lev  Paston  Cooper 
^shhurst,  Astley       ^  study 
Anatondcal  and  surg^  ^^^  ^^ 

fracutres  of  the  x 
^Yie  humerus 


WE810 
A825a 
1910 

Ashhurst,  Astley  Paston  Cooper 
Anatomical  and  svirgical  study  of 

fractures  of  the  lower  end  of  the 

humerus 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


